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Includes service urgency selection, referral service type (inpatient/outpatient/other), clinical procedure categories, and required diagnosis and billing codes (ICD-10 and CPT/HCPCS), plus dates of service and visit counts. 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| ☐ | Yes | ☐ | No |  |  |  |  | Motor Vehicle Accident related injury? |  |  |  |  |  | ☐ | Yes | ☐ | No |\n| Does the member have other insurance? |  |  |  |  |  | ☐ | Yes |  |  | ☐ | No | If Yes, other insurer |  |  |  |  |  |  |\n| Does the member have Medicare? |  |  |  | ☐ |  | Yes |  | ☐ |  | No |  |  | If Yes, | ☐ | Part A |  | ☐ | Part B |\n| *Service Is: ☐ Elective / Routine ☐ Expedited / Urgent |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Note: Select Expedited/ Urgent to prevent serious deterioration in health or jeopardize ability to regain maximum function. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| (For Claim Denial or Prior Authorization Denial, please submit an Appeal through Customer Service at 1-844-990-0255) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| * Referral Service Type Requested: Please review plans benefit prior to request |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Inpatient |  |  |  |  | Outpatient |  |  |  |  |  |  |  | Other |  |  |  |  |  |\n| ☐ Emergency Inpatient\u003Cbr>☐ Concurrent Review\u003Cbr>☐ Long-Term Acute\u003Cbr>☐ SNF\u003Cbr>☐ Rehab ☐ Transplant ☐ Maternity\u003Cbr>☐ Elective Admission/Surgery |  |  |  |  | ☐ Surgical Procedure\u003Cbr>☐ Imaging\u003Cbr>☐ Physical Therapy\u003Cbr>☐ Occupational Therapy\u003Cbr>☐ Speech Therapy ☐ Chemotherapy\u003Cbr>☐ Pain Management\u003Cbr>☐ Cosmetic/ Reconstructive |  |  |  |  |  |  |  | ☐ DNA/Genetic Testing\u003Cbr>☐ Orthotics/Prosthetics > $750\u003Cbr>☐ Lab Services ☐ Sleep Study\u003Cbr>☐ Other: |  |  |  |  |  |\n| Procedure Information: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| * ICD 10 Diagnosis: Diagnosis Description: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| *CPT/HCPC Code & Description (Include Unit of Measure / Frequency for supplies): |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| * Date(s) of Service: Number of Visits: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Provider Information: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Ordering Provider Is this the member’s Primary Care Physician? ☐ Yes ☐ No |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| * Name: * NPI TIN: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| * Phone: * Fax |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| *Address: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Servicing Provider Is this the same as the Ordering Provider? ☐ Yes ☐ No |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| If not complete below: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| * Name * NPI TIN: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| * Phone * Fax: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| *Address |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Facility |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| * Name: * NPI TIN: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| * Phone * Fax |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| *Address |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Request for extension to authorization request: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| ATTACH CLINICAL NOTES/SUMMARY TO SUPPORT MEDICAL NECESSITY. INCOMPLETE INFORMATION MAY DELAY THE PROCESS.\u003Cbr>Always verify eligibility, benefits and prior authorization requirements\u003Cbr>Note: Utilization Management (UM) functions are performed by Evolent Health\u003Cbr>Disclaimer: An authorization is not a guarantee of payment. Member mu","cbCaiuw5g9c9rVdC","https://ap.wps.com/l/cbCaiuw5g9c9rVdC","pdf",284878,"English","# Requestor and Patient Information\n## Service Type and Referral Details\n## Procedure, Diagnosis, and Billing Codes\n## Provider and Facility Information\n## Disclaimers and Confidentiality","[{\"question\":\"What information is required from the requestor and patient?\",\"answer\":\"The form collects requestor contact information and patient details such as name, DOB, member ID, and member phone, plus Medicare and other insurance information.\"},{\"question\":\"How does the form handle urgent or expedited service requests?\",\"answer\":\"It includes a choice for elective/routine versus expedited/urgent, with guidance to select expedited/urgent to prevent serious health deterioration or jeopardize functional recovery.\"},{\"question\":\"Which clinical and billing fields must be provided for the authorization request?\",\"answer\":\"Submit ICD-10 diagnosis with description and CPT/HCPCS code with description, including unit of measure or frequency for supplies, along with dates of service and number of visits.\"}]","SOMOS Prior Authorization Form - Behavioral Health - Submit Prior Authorization Details | PDF",1789633676]