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It also includes physician contact details, submission attribution, and authorization status outcomes (approved, denied, pended) plus required medical-necessity and contract-limit notes.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/nyc-healthline-fax-authorization-request-medical-management/283879/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/nyc-healthline-fax-authorization-request-medical-management/283879.png","ImageObject",442,249,{"name":42,"@type":43},"McGucket","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-11-02","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",14,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who is eligible to submit this NYC Healthline fax authorization request?","Question",{"text":63,"@type":64},"It is for City of New York employees and non-Medicare eligible retirees. Group numbers 157000-157699 apply.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What details are required to request authorization?",{"text":68,"@type":64},"The form requires member/subscriber information, patient demographics and relationship, emergency or scheduled selection, the service category, requested dates, and length of stay or number of visits.",{"name":70,"@type":61,"acceptedAnswer":71},"How does the form document diagnoses and procedures?",{"text":72,"@type":64},"It collects primary and secondary diagnosis details with ICD-10 codes, and records the procedure with the CPT-4 code.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283879,1790195216,{"code":4,"msg":82,"data":83},"success",[84,89,94,98,103,108,112,117,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":4},1236954412713,"https://us-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","NYC Healthline Fax Authorization Request Medical Management Fax 1-800-241-5308  \nFor City of New York Employees and non-Medicare eligible retirees (Group numbers 157000-157699)  \nMember/Subscriber information  \n\n| Last name | First name | ID no. |\n| --- | --- | --- |\n\nPatient information  \n\n| Last name | First name | Date of birth (MMDDYYYY)\u003Cbr>\u003Cbr>| Sex\u003Cbr> M  F |\n| --- | --- | --- | --- |\n| Relationship to Member/Subscriber:  Self  Spouse  Child |  |  |  |\n\nAuthorization requested from the NYC Healthline for: (check one service per fax form)  Emergency  Scheduled  \n\n|  | Inpatient acute\u003Cbr>Inpatient rehabilitation\u003Cbr>Maternity\u003Cbr>NICU\u003Cbr>Skilled nursing facility |  |  Ambulatory surgery  Air ambulance\u003Cbr> Cardiac rehabilitation\u003Cbr> DME or prosthetics  Genetic testing | |  | Infertility service\u003Cbr>Outpatient therapy:  PT  ST Radiology therapy\u003Cbr>Specialty drugs |\n| --- | --- | --- | --- | --- | --- | --- |\n|  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n| Admission date (MMDDYYYY)\u003Cbr>\u003Cbr>|  | Requested length of stay\u003Cbr>  days | First date of service (MMDDYYYY)\u003Cbr>\u003Cbr>| No. of visits requested | Authorization period requested\u003Cbr>  days |  |\n| Additional services continue to require precertification by EmblemHealth. Providers should call 1-800-223-9870 for precertification. |  |  |  |  |  |  |\n\nDiagnosis/Procedure information  \n\n| Primary diagnosis | ICD–10 code |\n| --- | --- |\n| Secondary diagnosis | ICD–10 code |\n| Procedure | CPT–4 code |\n\nFacility/Provider information  \n\n| Name |  | NPI |  |  |\n| --- | --- | --- | --- | --- |\n| Street address | City |  | State | ZIP code |\n\nPhysician information  \n\n| Name of ordering physician |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Provider NPI no. |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Phone no.: |  |  |  |  |  |  |  |  |  |  |  | Fax no.: |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Street address |  |  |  |  |  |  |  |  |  |  |  | City |  |  |  |  |  |  |  |  |  |  |  | State | ZIP code |\n\nFax request submitted by: For Anthem use only  \n\n| Name | Fax no. (if different than above) |\n| --- | --- |\n\n\n| Authorization Status:\u003Cbr> Approved: LOS authorized:   OR No. of visits:   for period of:   days authorized Authorization no.:   *Date authorization completed:         \u003Cbr> Denied: By:   Phone no.:  \u003Cbr> Pended: For Additional medical information:   For medical review:  \u003Cbr>Comments:   |\n| --- |\n| * This authorization is based upon medical necessity, subject to the terms and conditions of the member’s contract and is NOT a guarantee of payment. |\n\nServices provided by Anthem HealthChoice HMO, Inc. and/or Anthem HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.  \n58514NYPENEBS  \nNYBCBS-CM-061001-24 June 2024  \nReset Form  \nSave and Print","cbCaijcC6qTPisan","https://ap.wps.com/l/cbCaijcC6qTPisan","pdf",177168,"English","# Member/Subscriber information\n# Patient information\n# Authorization requested for services\n# Admission and service details\n# Diagnosis/Procedure information\n# Facility/Provider information\n# Physician information\n# Fax request submission\n# Authorization status and notes","[{\"question\":\"Who is eligible to submit this NYC Healthline fax authorization request?\",\"answer\":\"It is for City of New York employees and non-Medicare eligible retirees. Group numbers 157000-157699 apply.\"},{\"question\":\"What details are required to request authorization?\",\"answer\":\"The form requires member/subscriber information, patient demographics and relationship, emergency or scheduled selection, the service category, requested dates, and length of stay or number of visits.\"},{\"question\":\"How does the form document diagnoses and procedures?\",\"answer\":\"It collects primary and secondary diagnosis details with ICD-10 codes, and records the procedure with the CPT-4 code.\"}]","NYC Healthline Fax Authorization Request - Medical Management | PDF",1789621337]