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Includes member identification and plan details, referring provider information, and diagnosis fields using ICD-10 codes. Captures requested services for Part A (SNF post hospitalization, skill-in-place, and additional days) and outpatient diagnostic or service details with CPT codes and required provider contact data. 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It includes signature and completion date fields for the requesting party.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"When is prior authorization required for services?",{"text":113,"@type":109},"Prior authorization is required for services provided by any non-participating provider, and payment applies only to the medical services listed below according to the member handbook or certificate of coverage.",{"name":115,"@type":106,"acceptedAnswer":116},"What information is needed for Part B therapy services requests?",{"text":117,"@type":109},"Part B requests require therapy type (PT/OT/ST), evaluation date, planned frequency by days per week for weeks, whether goals are in place, whether goals were updated, and status of active participation, functional progress, and potential to improve. 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Payment is authorized only for the medical services noted below, and is subject to the limitations and exclusions as outlined in the Member Handbook/Certificate of Coverage. |  |\n| --- | --- |\n| MEMBER DATA | Member Name Date of Birth Member’s Plan ID\u003Cbr>    Is Referring Provider:  Plan NP\u003Cbr>Name of Nursing Facility Referring Provider  PCP 􀂆 Plan PA 􀂆 Other\u003Cbr>Diagnoses (ICD-10 Codes) Related to Auth Request ~~ ~~\u003Cbr>SERVICES REQUESTED (include copy of order or clinical note for out-of-network requests)\u003Cbr>􀂆 Part A SNF (post hospitalization) Start Date   \\# of Days Requested  \u003Cbr>􀂆 Part A Skill-in-Place Start Date   \\# of Days Requested  \u003Cbr>􀂆 Additional Part A Days Reason:   \\# of Days Requested \u003Cbr>􀂆 Outpatient Diagnostic or Service Date of Procedure/Service  CPT Code or Name of Procedure/Service:   Provider or Facility Name (REQUIRED):   Provider or Facility Contact Number (REQUIRED):  \u003Cbr>REQUEST FOR PART B THERAPY SERVICES (attach care plan, initial evaluation, and most recent therapy notes)\u003Cbr>􀂆 PT 􀂆 Initial Visits Date of Eval  Plan:   days per week for   week(s) Goals in Place? 􀂆 Y 􀂆 N\u003Cbr>􀂆 Additional PT Visits \\# requested  Plan:   days per week for   week(s) Goals updated? 􀂆 Y 􀂆 N Member Actively Participating? 􀂆 Y 􀂆 N Functional Progress Made? 􀂆 Y 􀂆 N Demonstrates Potential to Improve?􀂆Y 􀂆 N\u003Cbr>􀂆 OT 􀂆 Initial Visits Date of Eval  Plan:   days per week for   week(s) Goals in Place? 􀂆 Y 􀂆 N\u003Cbr>􀂆 Additional OT Visits \\# requested   Plan:   days per week for   week(s) Goals updated? 􀂆 Y 􀂆 N Member Actively Participating? 􀂆 Y 􀂆 N Functional Progress Made? 􀂆 Y 􀂆 N Demonstrates Potential to Improve?􀂆Y 􀂆 N\u003Cbr>􀂆 ST 􀂆 Initial Visits Date of Eval  Plan:   days per week for   week(s) Goals in Place? 􀂆 Y 􀂆 N\u003Cbr>􀂆 Additional ST Visits \\# requested   Plan:   days per week for   week(s) Goals updated? 􀂆 Y 􀂆 N Member Actively Participating? 􀂆 Y 􀂆N Functional Progress Made? 􀂆 Y 􀂆 N Demonstrates Potential to Improve?􀂆Y 􀂆 N |\n|  |  |\n| PART A and OUTPAT IENT SERV ICE |  |\n| PART B / THERAPY |  |\n\nTO BE COMPLETED BY PERSON REQUESTING AUTHORIZATION  \n Standard Authorization Request  \n Expedited Authorization (Must Read and SIGN): By signing below I certify that waiting for a decision longer than 72 hours could place the Member’s life, health, or ability to gain maximum function in serious jeopardy.  \nSignature for Expedited Review Only:    \nName of Person Completing this Form:  Date Completed:    \n(Please Print Name)  \nContact \\#:   Contact FAX:","cbCaipUJqvt5Gwjt","https://ap.wps.com/l/cbCaipUJqvt5Gwjt","pdf",336848,"English","# Member Data\n# Services Requested\n## Part A and Outpatient Service\n## Part B / Therapy\n# Authorization Request (To Be Completed By Requesting Person)","[{\"question\":\"Who must submit this authorization request form?\",\"answer\":\"The form is completed by the person requesting authorization of services. It includes signature and completion date fields for the requesting party.\"},{\"question\":\"When is prior authorization required for services?\",\"answer\":\"Prior authorization is required for services provided by any non-participating provider, and payment applies only to the medical services listed below according to the member handbook or certificate of coverage.\"},{\"question\":\"What information is needed for Part B therapy services requests?\",\"answer\":\"Part B requests require therapy type (PT/OT/ST), evaluation date, planned frequency by days per week for weeks, whether goals are in place, whether goals were updated, and status of active participation, functional progress, and potential to improve. A care plan and therapy notes must be attached.\"}]","Request for Authorization of Services Form | PDF",1789632047]