[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288907-105":53,"doc-detail-288907-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","prior-authorization-request-form-providence-health-assurance","Prior Authorization Request Form - Providence Health Assurance","","This document is a formal prior authorization request form issued by Providence Medicare Advantage Plans, a division of Providence Health Assurance. It is designed for healthcare providers to submit requests for specific medical services, imaging, or procedures requiring pre-approval. The form captures comprehensive details including member information, primary care physician data, requesting and servicing provider credentials (TIN and NPI numbers), and specific service codes such as ICD-10 and CPT. It also includes sections for elective inpatient or outpatient surgery, diagnostic services, durable medical equipment (DME) requests, and justifications for out-of-network services. The form requires contact information for follow-up and provides a pathway for expedited reviews when a member's health status necessitates urgent processing.",{"@graph":63,"@context":119},[64,80,102],{"@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/prior-authorization-request-form-providence-health-assurance/288907/",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/prior-authorization-request-form-providence-health-assurance/288907.png","ImageObject",442,249,{"name":88,"@type":89},"Seraphina","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-10","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",7,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information is required for the requesting and servicing providers?","Question",{"text":109,"@type":110},"The form requires the name, address, Tax Identification Number (TIN#), and National Provider Identifier (NPI#) for both the requesting provider, the servicing provider, and the servicing facility.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"When should an expedited review be requested?",{"text":114,"@type":110},"An expedited review should be requested when a member's life, health, or ability to regain maximum function would be in serious jeopardy if a determination is not made within the standard timeframe; this requires supporting documentation.",{"name":116,"@type":107,"acceptedAnswer":117},"What details are needed for out-of-network service requests?",{"text":118,"@type":110},"When requesting services from an out-of-network provider or facility, the form requires supporting documentation explaining why the services cannot be provided by an in-network provider, as well as the patient status and date last seen.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},288907,1790202792,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},962075114101,"https://ap-avatar.wpscdn.com/avatar/e000253a75eb197efd?x-image-process=image/resize,m_fixed,w_180,h_180&k=1780044092746381165","| For High Tech\u003Cbr>Imaging | American Imaging Management (AIM) | Phone: 800-920-1250 | [http://www.americanimaging.net/goweb/](http://www.americanimaging.net/goweb/)\u003Cbr>[| For Registration](| For Registration: Providence PIN #: 045-83169)[:](| For Registration: Providence PIN #: 045-83169)[ ](| For Registration: Providence PIN #: 045-83169)[Providence PIN \\#: 045-83169](| For Registration: Providence PIN #: 045-83169) |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Member Information |  |  |  |  |  |\n| Last Name: |  | First Name: |  |  |  |\n| Insurance ID \\#: |  | DOB: |  |  |  |\n| Address: |  | Date of Service: |  |  | Date Span\u003Cbr>Requested: |\n| Primary Care Physician (PCP): |  |  |  |  |  |\n| Requesting Provider: |  |  |  | TIN\\#: |  |\n| Address: |  |  |  | NPI\\#: |  |\n| Servicing Provider: |  |  |  | TIN\\#: |  |\n| Address: |  |  |  | NPI\\#: |  |\n| Servicing Facility: |  |  |  | TIN\\#: |  |\n| Address: |  |  |  | NPI\\#: |  |\n| Requested Item/Service: |  |  |  |  |  |\n| ICD-10 Code(s): |  |  | CPT Code(s): |  |  |\n| Requested Services:\u003Cbr>☐ Office Visits, \\# of visits:   ☐ Surgery | ☐ Diagnostic | ☐ Facility Auth Only | ☐ DME | Other   |  |  |  |  |  |\n| Type of Service:\u003Cbr>☐ Elective Inpatient Admit | ☐ Elective Outpatient Surgery | ☐ Office Surgery | ☐ Outpatient Diagnostics | ☐ ASC |  |  |  |  |  |\n| Expedite-defined as member’s life, health or ability to regain maximum function is in serious jeopardy if determination is not made in the standard timeframe. Request must include supporting documentation to substantiate an expedited review.\u003Cbr>Explanation Required: |  |  |  |  |  |\n| In-Network Benefits: Request must include supporting documentation to substantiate why services cannot be provided by an innetwork provider/facility. ☐ New Patient ☐ Established Patient | Date last seen  \u003Cbr>Explanation Required: |  |  |  |  |  |\n| **REQUIRED** Contact Information: |  |  |  |  |  |\n| Name: |  | Phone \\#: |  |  | Fax\\#: |","cbCaifNajfiPPodu","https://ap.wps.com/l/cbCaifNajfiPPodu","pdf",175289,"English","# Member Information\n# Provider and Facility Details\n# Service Request Information\n## ICD-10 and CPT Coding\n## Service Categories\n# Justification and Contact Information\n## Expedited Review Requirements\n## Out-of-Network Justification","[{\"question\":\"What information is required for the requesting and servicing providers?\",\"answer\":\"The form requires the name, address, Tax Identification Number (TIN#), and National Provider Identifier (NPI#) for both the requesting provider, the servicing provider, and the servicing facility.\"},{\"question\":\"When should an expedited review be requested?\",\"answer\":\"An expedited review should be requested when a member's life, health, or ability to regain maximum function would be in serious jeopardy if a determination is not made within the standard timeframe; this requires supporting documentation.\"},{\"question\":\"What details are needed for out-of-network service requests?\",\"answer\":\"When requesting services from an out-of-network provider or facility, the form requires supporting documentation explaining why the services cannot be provided by an in-network provider, as well as the patient status and date last seen.\"}]","Prior Authorization Request Form - Providence Health Assurance | PDF",1789634198]