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Provides fax and phone routing for standard, expedited, transplant, and behavioral health requests, along with timelines for determinations. Collects member, requesting provider, and servicing provider/facility details plus authorization request fields including procedure codes, diagnosis code (ICD-10), dates, and total units or visits. 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Existing Authorization Units  \nAll Part B Drug Requests: Fax 844-978-0975  \nExpedited Requests: Call 888-445-8913  \nTransplant Requests: Fax 833-590-1582  \nBehavioral Health Requests: Fax 855-663-2244  \nStandard Requests: Fax 844-692-4065  \nFor Standard requests, complete this form and FAX to the appropriate department. Determination made as expeditiously as the enrollee’s health condition requires, but no later than 14 calendar days after receipt of request.  \nFor Expedited requests, Please Call 888-445-8913. Expedited requests are made when the enrollee or his/her physician believes that waiting for a decision under the standard timeframe could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy.  \n* INDICATES REQUIRED FIELD    \nDate of Birth*  \nMEMBER INFORMATION   \nMember ID* Last Name, First (MMDDYYYY)  \nREQUESTING PROVIDER INFORMATION  \nRequesting NPI* Requesting TIN* Requesting Provider Contact Name  \n*  \nRequesting Provider Name Phone Fax  \nSERVICING PROVIDER / FACILITY INFORMATION  \n  Same as Requesting Provider  \n*  \nServicing NPI  \nServicing Provider/Facility Name  \nServicing TIN*  \nPhone  \nServicing Provider Contact Name  \nFax  \nAUTHORIZATION REQUEST  \n*1650*  \nPrimary Procedure Code*  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS)  \nAdditional Procedure Code  \n(CPT/HCPCS)  \n*  \nStart Date OR Admission Date  \n(MMDDYYYY)  \nEnd Date OR Discharge Date  \n(MMDDYYYY)  \nDiagnosis Code*  \n(ICD-10)  \nTotal Units/Visits/Days  \n| OUTPATIENT SERVICE TYPE*\u003Cbr>422 Biopharmacy (please fax to 844-978-0975)\u003Cbr>712 Cochlear Implants & Surgery\u003Cbr>299 Drug Testing\u003Cbr>922 Experimental & Investigational Services\u003Cbr>205 Genetic Testing & Counseling\u003Cbr>249 Home health\u003Cbr>290 Hyperbaric Oxygen Therapy\u003Cbr>395 Infertility Diagnosis or Treatment\u003Cbr>729 Neuropsychological Testing\u003Cbr>410 Observation\u003Cbr>997 Office Visit/Consult | (Enter the Service type number in the boxes)  |  |\n| --- | --- | --- |\n|  | 794 Outpatient Services\u003Cbr>171 Outpatient Surgery\u003Cbr>202 Pain Management\u003Cbr>650 Radiation Therapy\u003Cbr>428 Second Opinion\u003Cbr>201 Sleep Study\u003Cbr>212 Therapy Evaluation\u003Cbr>790 Occupational Therapy\u003Cbr>101 Physical Therapy\u003Cbr>701 Speech Therapy\u003Cbr>993 Transplant Evaluation\u003Cbr>209 Transplant Surgery\u003Cbr>724 Transportation | \u003Cbr>\u003Cbr>\u003Cbr>Behavioral Health\u003Cbr>533 BH Applied Behavioral Analysis DME (Orthotics and Prosthetics)\u003Cbr>512 BH Community Based Services 417 Rental\u003Cbr>120 Purchase\u003Cbr>515 BH Electroconvulsive Therapy\u003Cbr>516 BH Intensive Outpatient Therapy (IOP) (Purchase Price)\u003Cbr>510 BH Medical Management\u003Cbr>518 BH Mental Health /Chemical Dependency Observation\u003Cbr>519 BH Outpatient Therapy\u003Cbr>530 BH Partial Hospitalization Program (PHP)\u003Cbr>520 BH Professional Fees\u003Cbr>522 BH Psychiatric Evaluation\u003Cbr>521 BH Psychological Testing\u003Cbr>Are services needed for discharge planning?\u003Cbr>YES NO |\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 Health Plan Benefit and medically necessary with prior authorization as per Plan 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. 05 06 2025 XO-PAF-1650","cbCaic4C6fpxU28Z","https://ap.wps.com/l/cbCaic4C6fpxU28Z","pdf",852958,"English","# Authorization Request Routing\n## Determination Timelines and Contact Information\n# Required Member and Provider Information\n## Member Information\n## Requesting Provider Information\n## Servicing Provider/Facility Information\n# Authorization Request Details\n## Procedure Codes and Diagnosis Code\n## Dates and Total Units/Visits/Days\n# Outpatient Service Type Selection\n## Service Type Code List\n# Discharge Planning and Compliance Notices","[{\"question\":\"Where should standard outpatient authorization requests be sent?\",\"answer\":\"For Standard requests, complete the form and fax it to the appropriate department.\"},{\"question\":\"When are expedited requests allowed for Medicare outpatient authorization?\",\"answer\":\"Expedited requests are made when waiting under the standard timeframe could seriously jeopardize the enrollee’s life, health, or ability to regain maximum function, based on the enrollee or physician’s belief.\"},{\"question\":\"What happens if required fields or supporting clinical information are missing?\",\"answer\":\"Incomplete forms will be rejected, and lack of clinical information may result in delayed determination. All required fields marked as required must be filled in.\"}]","MEDICARE - OUTPATIENT AUTHORIZATION - Oregon Healthnet - Rev. 05 06 2025 | PDF",1789633212]