Prior Authorization General Request for Elective Surgery, Procedure, Service or DME

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* Required Field

Enter Patient Information

  • Review Type:
  • Patient First Name: *
  • Patient Middle Initial:
  • Patient Last Name: *
  • Date of Birth: *
  • Patient Group ID: *
  • IDC-10 Diagnosis Codes: *
  • Diagnosis Codes must be 3-8 characters with NO decimals
    Codes must be 3 - 8 characters and no decimals.
  • CPT or HCPCS Codes: *
    (Include modifiers if applicable)
  • CPT/HCPCS codes must contain 5-9 charactersUnits may contain up to 3 characters
    Units:
  •  
  • High Tech Radiology authorizations may go through eviCore. Please call for benefits prior to submission.
  • Date of Service/Admission Date: *
  • Procedure is scheduled as: *
  • 23-hr observation Outpatient Inpatient

* Required Field

Enter Provider Information

  • Contact First Name: *
  • Contact Last Name: *
  • Contact Email Address:
  • Contact Phone No:*
  • Contact Phone Ext:
  • Contact Fax No:*
  • Provider ID OR NPI: *
  •  
    • I am an Ordering Physician
    • I am a Servicing Physician
  • Ordering Physician's Name:
  • Ordering Physician's Address:
  • Ordering Physician's City:
  • Ordering Physician's State:
  • Ordering Physician's Zip:
  • Ordering Physician's Email Address:
  • Ordering Physician's Phone No:
  • Ordering Physician's Fax No:
  • Servicing Physician's Name:
  • Servicing Physician's Address:
  • Servicing Physician's City:
  • Servicing Physician's State:
  • Servicing Physician's Zip:
  • Servicing Physician's Email Address:
  • Servicing Physician's Phone No:
  • Servicing Physician's Fax No:
  • Facility/Supplier Name: *
  • Facility NPI:
  • Facility/Supplier Address: *
  • Facility/Supplier City: *
  • Facility/Supplier State: *
  • Facility/Supplier Zip: *

Proposed Intervention: *

History of condition (including duration of condition, previous failed conservative treatments, etc.): *

Signs and symptoms that justify the intervention (such as ominous characteristics of a lesion—size, shape, pigmentation and growth changes, failure of conservative treatments, complication of the current management plan, etc.): *

Durable Medical Equipment (DME)

  • New
  • Replacement
  • Other

Please attach relevant clinical documentation.*

Choose a file or files to attach * (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







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If you experience issues submitting this form, please print and fax it to (816) 817-8211.

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ID Number

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Suffix

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

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