[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283759-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283759-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","prior-authorization-form-aspirus-health-plan","Prior Authorization Form - Aspirus Health Plan","","Prior Authorization Form collects required member and provider details to support a request for covered medical services through Aspirus Health Plan. The form captures request date, service start date, patient identity, ordering and servicing provider information, and coverage notes. It includes selections for service type, primary diagnosis codes, procedure/HCPCS codes, and space for treatment indications and attached clinical documentation. It also states that authorization does not guarantee benefits or payment and approval depends on medical necessity per the benefit plan.",{"@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/prior-authorization-form-aspirus-health-plan/283759/",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/prior-authorization-form-aspirus-health-plan/283759.png","ImageObject",442,249,{"name":42,"@type":43},"WPS_1786070896","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-26","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",9,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Where should the completed prior authorization form and supporting documents be sent?","Question",{"text":63,"@type":64},"Send the completed form and applicable supporting clinical documents to Aspirus Health Plan, Attn: Medical Management, PO Box 1890, Southampton, PA 18966, or fax it to 763.847.4014.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What patient and provider information does the form require?",{"text":68,"@type":64},"The form requests patient last and first name, member ID, and patient date of birth, plus ordering and servicing provider details including names, site/location information, NPI, TIN, addresses, and contact phone/fax.",{"name":70,"@type":61,"acceptedAnswer":71},"Does prior authorization guarantee benefits or payment?",{"text":72,"@type":64},"No. Prior authorization of any procedure does not guarantee benefits or payment; approval is based on medical necessity defined in the patient’s benefit plan or certificate.","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},283759,1790206958,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"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":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":4},549768072016,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Prior Authorization Form  \nPlease return the completed form and applicable supporting clinical documents to: Aspirus Health Plan, Attn: Medical Management, PO Box 1890, Southampton, PA 18966  \nor Fax: 763.847.4014  \n\n| DATE OF REQUEST |  |\n| --- | --- |\n| START DATE OF SERVICES |  |\n\n\n| PATIENT INFORMATION |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| Patient Last Name | Patient First Name |  |  | Member ID |  | Patient Date of Birth |  |\n| ORDERING PROVIDER INFORMATION |  |  |  |  |  |  |  |\n| Ordering Provider Name |  |  |  |  |  | NPI |  |\n| Site/Location Name |  |  |  | TIN |  | NPI |  |\n| Site/Location Address |  | City |  |  | State |  | ZIP |\n| Site/Location Contact Person |  | Phone |  |  | Fax |  |  |\n|  Fax notifications related to this request (by checking this box, you will not receive mail notifications). |  |  |  |  |  |  |  |\n| SERVICING PROVIDER INFORMATION |  |  |  |  |  |  |  |\n|  Check if servicing provider is same as ordering provider. |  |  |  |  |  |  |  |\n| Servicing Provider Name |  |  |  |  |  | NPI |  |\n| Site/Location Name |  |  |  | TIN |  | NPI |  |\n| Site/Location Address |  | City |  |  | State |  | ZIP |\n| Site/Location Contact Person |  | Phone |  |  | Fax |  |  |\n| Comments (indications for treatment) |  |  |  |  |  |  |  |\n| SERVICES REQUESTED (Supporting clinical documentation must accompany this request) |  |  |  |  |  |  |  |\n|  Consult Only  Follow-Up  DME  Lab/X-Ray  Home Care  Hospice  Skilled Nursing\u003Cbr> Outpatient Therapy (Physical, Occupational, Speech):  Habiliatative  Rehabiliatative\u003Cbr> Surgery:  Inpatient  Outpatient  Other   |  |  |  |  |  |  |  |\n| Primary Diagnosis Code |  |  | Description |  |  |  |  |\n| Procedure/HCPCS Code(s) |  |  | Description |  |  |  |  |\n| Attach Applicable Office Notes and Diagnostic Testing Results For This Request\u003Cbr>Workers Compensation  Yes  No Date of Injury/Loss  \u003Cbr>Motor Vehicle Accident/Subro  Yes  No Date of Injury/Loss  \u003Cbr>Other Coverage  Yes  No Insurance Company   |  |  |  |  |  |  |  |\n\nNOTE: The prior authorization of any procedure does not guarantee benefits or payment. Approval is based on medical necessity as defined in the patient’s benefit plan or certificate. All benefits are subject to the terms, conditions, and exclusions of the benefit plan or certificate. This may include policy language regarding pre-existing conditions or signed affidavits stating that the insurance bears no responsibility, as signed by the insured. Policy exclusions for certain types of services may also apply. Verify prior authorization requirements. For additional benefit information, please contact Aspirus Health Plan at 866.631.5404. A release of information form included in the application for insurance was signed by our member.  \n30654 11-24 ©2024 Aspirus Health Plan, Inc. All rights reserved.","cbCaiqLhYBkcmy36","https://ap.wps.com/l/cbCaiqLhYBkcmy36","pdf",70812,"English","# Patient and Request Details\n## Date of request and start date\n# Patient Information\n## Patient identifiers\n# Provider Information\n## Ordering provider\n## Servicing provider\n# Services Requested\n## Service type selections\n## Diagnosis and procedure codes\n## Supporting clinical documentation checklist","[{\"question\":\"Where should the completed prior authorization form and supporting documents be sent?\",\"answer\":\"Send the completed form and applicable supporting clinical documents to Aspirus Health Plan, Attn: Medical Management, PO Box 1890, Southampton, PA 18966, or fax it to 763.847.4014.\"},{\"question\":\"What patient and provider information does the form require?\",\"answer\":\"The form requests patient last and first name, member ID, and patient date of birth, plus ordering and servicing provider details including names, site/location information, NPI, TIN, addresses, and contact phone/fax.\"},{\"question\":\"Does prior authorization guarantee benefits or payment?\",\"answer\":\"No. Prior authorization of any procedure does not guarantee benefits or payment; approval is based on medical necessity defined in the patient’s benefit plan or certificate.\"}]","Prior Authorization Form - Aspirus Health Plan | PDF",1789618808]