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\\#:\u003Cbr>808.948.6464 (Oahu)\u003Cbr>800.344.6122 (NI)\u003Cbr>800.877.5394 (Mainland) Website: [hhin.hmsa.com](hhin.hmsa.com) |  |  |  |  |  |\n|  |  |  |  |  | Fax \\#: 888.881.8225 Phone \\# for Expedited:\u003Cbr>888.505.1201 (Medicare)\u003Cbr>888.846.4262 (Medicaid) Website: [provider.wellcare.com](provider.wellcare.com) |  |  |  |\n| Fax \\#: 808.973.0676 (Oahu)\u003Cbr>888.667.0680 (NI) Phone \\#: 808.973.0712 [Website:](Website: www.alohacare.org)[ ](Website: www.alohacare.org)[www.alohacare.org](Website: www.alohacare.org) |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  | Fax \\#: 800.267.8328 Phone \\#: 888.980.8728 Website:\u003Cbr>[www.uhcprovider.com](www.uhcprovider.com) |  |\n| 􀂅 Standard request | For Medicare and Medicaid plans: decision & notification are made within 7 calendar days*\u003Cbr>For HMSA Commercial, Federal and EUTF plans: decisions & notification are made within 15 calendar days* |  |  |  |  |  |  |  |\n| 􀂅 Expedited request\u003Cbr>(MD, PA, RN, RD or LPN) Signature required) | Decision & notification are made within 72 hours* or as expeditiously as this member’s health condition requires if urgent criteria are met.\u003Cbr>By signing below, I certify that following the standard timeframe could seriously jeopardize this member’s life or health or ability to attain, maintain, or regain maximum function. |  |  |  |  |  |  |  |\n|  | Signature (if left blank, request will be reviewed based on standard timeframes) Date signed |  |  |  |  |  |  |  |\n| 􀂅 Retrospective | Retrospective authorization is defined as a request for services that have been rendered but a claim has not been submitted. |  |  |  |  |  |  |  |\n\n*From receipt of request, provided that all relevant supporting clinical information and documentation are submitted.  \nTo avoid delays, please attach supporting documents  \nA. Member information  \nMembership ID Patient’s Name (Last, First MI) Date of birth (MM/DD/YYYY)  \nMember’s Physical Address Phone \\#  \nB. ICD-10-CM diagnosis code(s)  \nDiagnosis code(s): ~~ ~~ ~~ ~~      \nC. Procedure/service/treatment information  \nPlace of service:  Inpatient  Outpatient/ASC (ambulatory surgical center)  Labs and diagnostic (outpatient)  Office  Home  \nFor Rehab Services (check one) : PT  OT Speech  Initial  Continuing Last Date of Service:   Total Visits Used:   \n| CPT/HCPCS code(s) | Cost of DME | Modifier | \\# of units | CPT/HCPCS code(s) | Cost of DME | Modifier | \\# of units |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n\nService date(s): ~~ ~~ to ~~ ~~  Hospital Discharge  \nD. Provider information  \n\n| Requesting (or referring) provider name | Provider NPI |\n| --- | --- |\n| Address\u003Cbr>|  |\n| Contact Name Phone No.\u003Cbr>| Fax No. |\n| Servicing Provider/Facility/Vendor (if different from requesting or referring provider) | Provider NPI |\n| Address |  |\n\nContact Name Phone No. Fax No.  \nE. General Comments  \nPriorAuth.Allplan_Form 01/01/2026","cbCaikg54v1ptk0e","https://ap.wps.com/l/cbCaikg54v1ptk0e","pdf",200589,"English","# Request Type and Timelines\n## Standard Request\n## Expedited Request\n## Retrospective Authorization\n# Member Information\n# Diagnosis Codes (ICD-10-CM)\n# Procedure/Service/Treatment Information\n## Place of Service\n## Rehab Services\n## CPT/HCPCS Codes and Units\n## Service Dates\n# Provider Information\n## Requesting/Referring Provider\n## Servicing Provider/Facility/Vendor\n# General Comments and Signature","[{\"question\":\"该表单支持哪些类型的Prior Authorization请求？\",\"answer\":\"表单包含标准请求、加急请求以及追溯（retrospective）授权三种类型，并分别说明了决策与通知时效要求。\"},{\"question\":\"加急请求需要哪些条件与签名要求？\",\"answer\":\"加急请求在满足紧急标准时以72小时内作出决策与通知为目标；需由指定人员完成签名，并证明延用标准时效可能严重危及成员生命或健康。\"},{\"question\":\"表单中需要提供哪些关键信息用于审核？\",\"answer\":\"通常需要成员信息、ICD-10-CM诊断代码、程序/服务/治疗信息（如CPT/HCPCS代码、单位、服务地点与日期）以及请求/转诊与服务方提供者的NPI与联系信息，并可附支持文件以避免延误。\"}]","Prior Authorization Request Form | PDF",1789621006]