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Collects member details, ordering and servicing provider identifiers, procedure codes (CPT/HCPCS) with modifiers, start/admission and discharge dates, and ICD-10 diagnosis codes. Includes inpatient service type selection and specific options for behavioral health and substance use. Requires required fields to be completed, supporting clinical documents to be attached, and urgent requests to be physician-signed for priority consideration. Includes HIPAA confidentiality and non-guarantee of payment disclaimer.",{"@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-rev-09-03-2020-ew-paf-0686/288820/",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-rev-09-03-2020-ew-paf-0686/288820.png","ImageObject",442,249,{"name":88,"@type":89},"Adam","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-13","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":20},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What is the form used for?","Question",{"text":108,"@type":109},"It is used to request prior authorization for inpatient services by submitting member, provider, procedure, and diagnosis information.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How are urgent requests handled?",{"text":113,"@type":109},"Urgent requests require the member’s request to be certified as urgent and medically necessary within 48 hours, and urgent requests must be signed by the physician to receive priority.",{"name":115,"@type":106,"acceptedAnswer":116},"What happens if required fields or supporting clinical information are missing?",{"text":117,"@type":109},"Incomplete forms will be rejected. Missing supporting clinical information may result in delayed determination.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288820,1791454533,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":20,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},1374404737137,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","INPATIENT  \nPRIOR AUTHORIZATION FORM  \nComplete and Fax to: Medical 855-218-0592 Behavioral 833-286-1086 Transplant 833-552-1001  \nStandard requests- Determination within 5 calendar days of receiving all necessary information.  \nUrgent requests-  \nI certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within 48 hours to avoid complications and unnecessary suffering or severe pain.  \nX  \nURGENT REQUESTS MUST BE SIGNED BY THE PHYSICIAN TO RECEIVE PRIORITY  \n* Indicates Required Field ~~ ~~  \nMEMBER INFORMATION  \n*Member ID  \nLast Name, First  \n*Date of Birth  \n(MMDDYYYY)  \nORDERING PROVIDER INFORMATION  \n*Ordering NPI *Ordering TIN Ordering Provider Contact Name  \n*0686*  \nOrdering Provider Name Phone *Fax  \nSERVICING PROVIDER / FACILITY INFORMATION  \n Same as Ordering Provider  \n*Servicing NPI *Servicing TIN Servicing Provider Contact Name  \nServicing Provider/Facility Name  \nAUTHORIZATION REQUEST  \n*Primary Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nPhone Fax  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \n*Start Date OR Admission Date  \n(MMDDYYYY)  \nDischarge Date (if applicable) otherwise  \nLength of Stay will be based on Medical Necessity  \n(MMDDYYYY)  \n*Diagnosis Code  \n(ICD-10)  \nAdditional Diagnosis Code  \n(ICD-10)  \n\n| *INPATIENT SERVICE TYPE (Enter the Service type number in the boxes) |  |  |\n| --- | --- | --- |\n| Delivery\u003Cbr>779 C-Section Delivery 720 Vaginal Delivery\u003Cbr>Inpatient Rehab\u003Cbr>427 Rehab\u003Cbr>Transplant\u003Cbr>992 Transplant | Miscellaneous\u003Cbr>121 Long Term Acute Care\u003Cbr>970 Medical\u003Cbr>414 Premature/False Labor\u003Cbr>402 Skilled Nursing Facility\u003Cbr>411 Surgical\u003Cbr>490 Boarder Baby\u003Cbr>300 Neonate | Behavioral Health-please send all supporting forms and medical records as necessary based on service\u003Cbr>528 Chemical Substance Abuse-circle appropriate option:\u003Cbr>ASAM: 3.2 3.7 4.0 AND Involuntary Voluntary\u003Cbr>532 Crisis Stabilization Unit\u003Cbr>531 Eating Disorders\u003Cbr>529 Psychiatric Admission-circle appropriate option: Involuntary Voluntary\u003Cbr>536 Residential Treatment-Mental Health -circle appropriate option:\u003Cbr>Short Term (less than 30 days) Long Term (greater than 30 days)\u003Cbr>535 Residential Treatment-Substance Use-circle appropriate option: ASAM: 3.1 3.3 3.5 |\n\nALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED.  \nCOPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION.  \nDisclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered benefit and medically necessary with prior authorization as per Ambetter policy and procedures.  \nConfidentiality: The information contained in this transmission is confidential and may be protected under the Health Insurance Portability and Accountability Act of 1996. If you are not the intended recipient any use, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and destroy this document.  \nRev.09 03 2020 EW-PAF-0686","cbCaivnSbaWsO7OC","https://ap.wps.com/l/cbCaivnSbaWsO7OC","pdf",466087,"English","# Member Information\n# Ordering Provider Information\n# Servicing Provider / Facility Information\n# Authorization Request\n## Procedure and Diagnosis Codes\n## Inpatient Service Type\n## Urgent Request Requirements\n# Required Attachments and Disclaimers","[{\"question\":\"What is the form used for?\",\"answer\":\"It is used to request prior authorization for inpatient services by submitting member, provider, procedure, and diagnosis information.\"},{\"question\":\"How are urgent requests handled?\",\"answer\":\"Urgent requests require the member’s request to be certified as urgent and medically necessary within 48 hours, and urgent requests must be signed by the physician to receive priority.\"},{\"question\":\"What happens if required fields or supporting clinical information are missing?\",\"answer\":\"Incomplete forms will be rejected. Missing supporting clinical information may result in delayed determination.\"}]","Inpatient Prior Authorization Form - Rev. 09 - 03 2020 - EW-PAF-0686 | PDF",1789634015]