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Designed to be completed by the clinician with knowledge of the patient’s presentation and treatment history, with submission via fax or authorization phone call. Collects requested level of care, admission details, contact and patient information, facility and provider data, possible network exception rationale, ER admission details, and condition-specific clinical questions, plus supporting clinical attachments when applicable.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/inpatient-prior-authorization-form-fax-submission-instructions/288680/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/inpatient-prior-authorization-form-fax-submission-instructions/288680.png","ImageObject",442,249,{"name":88,"@type":89},"Valentina","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who 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behavioral and substance use services,including mental health,detox,substance use rehabilitation,dual diagnosis,and eating disorder treatment.  \n·  This authorization request form should be completed by the clinician who has knowledge of the Evernorth customer's currentclinical presentation and treatment history.  \n·  Please note:Evernorth may release the information contained in this form to the customer or the customer's representative.  \nPlease complete this form and faxit to 833.213.9320.  \nIfyou are unable to submit your requests via fax,please call 800.926.2273 for authorization.  \nTIPSFOR COMPLETING THISFORM:  \n·  Verify coverage prior to submitting this request.  \n·To help expedite processing,please complete all sections as specifically and clearly as possible.  \n·Typed responses are preferred.  \n·Omissions,generalities,andillegibility may result in this request being returned for completion or clarification.  \n·  Please note that Evernorth assumes no responsibility for the protection of electronically transmitted information prior to itsactual receipt of that information.It is your responsibility to take any steps necessary to protect the email or documents priorto receipt by Evernorth.  \n1.Level of care requested:    Inpatient mental health    Inpatient detox□Inpatient substance use rehabilitation  \n□Inpatient dual diagnosis □Inpatient eating disordertreatment  \n/    /      \n2.Date of admission to behavioral unit:        \nAdmission status to behavioral unit:□Waiting □Admitted  \n3.Name of primary contact for initial request:                                    \nDirect telephone number:                \nFax number(for follow up/authorization information):                \n## 4.Patient information\n\n/____  \n/      \n                    Member ID\\#:           \nPatient date of birth:        \nPatient current home address:  \nLast four digits of the policyholder's social security number (optional):          \nIs the patient their own guardian?          \na.If yes,please provide patient's telephone number:              \nb.f no,please provide parent/guardian name:                                      \nParent/guardian telephone number:                \n## 5.Facility information\n\nRequesting facility name:                                                                  \nRequesting facility Taxpayer ldentification Number(TIN):                      \nRequesting facility servicing address:  \nIf the requesting and servicing facilities are not the same,please complete the following:  \nServicing facility name:  \nServicing facility Taxpayer ldentification Number(TIN):  \nServicing facility servicing address:  \n924839 Rev.12/2025  \n## 6.For out-of-network facilities,is this a network exception request(NER)?\n\n       \nNote:Depending on the account,an NERmay not apply.  \nIf yes,what is the clinical rationale for requesting the NER?  \nPlease describe if any clinical treatment specialties are relevant for this patient and would be uniquely available from this facilityas opposed to another facility in our existing network.  \nIf no,is the customer aware they are using out of network benefits?          \n## 7.Attending provider(MD-level)information\n\nProvider name:                                                                    \nProvider facility Taxpayer Identification Number(TIN)or National Provider Identifier(NPI):                              \nAttending MD Address:                                                                              \n8.Utilization review(UR)contact for continued stay reviews  \nContact name:  \nContact telephone number:              \nContact fax number:                      \n## 9.Has the patient been admitted through the emergency room(ER)?\n\n       \nIf yes,please provide the following information:Date of ER admission:  1  Time of ER admission (please specify a.m.orp.","cbCaitq0iVJVW8pw","https://ap.wps.com/l/cbCaitq0iVJVW8pw","pdf",256589,"English","# Inpatient Prior Authorization Form\n## Submission and completion tips\n## 1. Level of care requested\n## 2. Admission details\n## 3. Primary contact information\n## 4. Patient information\n## 5. Facility information\n## 6. Out-of-network exception request (NER)\n## 7. Attending provider information\n## 8. Utilization review (UR) contact\n## 9. Emergency room (ER) admission\n## 10. Bed search needed\n## 11. Behavioral diagnosis codes\n## 12. Involuntary admission\n## 13. Inpatient mental health clinical questions\n## 14. Inpatient detox clinical question\n## 15. Required clinical attachments","[{\"question\":\"Who should complete the inpatient prior authorization request form?\",\"answer\":\"The clinician who knows the Evernorth customer’s current clinical presentation and treatment history should complete it.\"},{\"question\":\"How should the authorization request be submitted if fax is available?\",\"answer\":\"Complete the form and fax it to 833.213.9320.\"},{\"question\":\"What clinical information must be attached if the mental health and detox questions are answered no?\",\"answer\":\"Provide admission reason with precipitating events, baseline functioning, mental status exam, treatment history, family history, and additional sections such as substance use history, supports and living environment, medications, vitals/labs, motivation, current providers, and treatment goals.\"}]","Inpatient Prior Authorization Form - Fax Submission Instructions | PDF",1789633775]