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

Loading...

• * Required Field

• Enter Patient Information

• Patient Group ID: *
• Review Type: * Standard Expedited
• Procedure is scheduled as: * Outpatient Inpatient
• Treatment Type: * Maternity Medical Pediatric Medical
  Pediatric Surgical Medical
  Surgical
• Place of Service: * Outpatient Ambulatory Surgical Center Office Patient Home
  Nursing Facility
•  
• Date of Service/
  Expected Admission Date: *
• Frequency/Length of Time Needed:
• Start Date: *
• End Date: *
• ICD-10 Diagnosis Codes: *

  Diagnosis Codes must be 3-8 characters along with decimals

  Codes must be 3 - 8 characters along with decimals.
  +
• • CPT or HCPCS Codes: *
  •  
  •  

• • (Include modifiers if applicable)

  • Units: *
  •  
• • +

  High Tech Radiology authorizations may go through eviCore.
  Please call for benefits prior to submission.

• Devices Planned for Use:
• Blue KC ID (Not SS#): *
  • i
  • i
  • i
• Patient First Name: *
• Patient Middle Initial:
• Patient Last Name: *
• Date of Birth: *

• * 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: *
• Requesting Physician/Provider Name:
• Requesting Physician/Provider NPI: *
• Requesting Physician's Address:
• Requesting Physician's City:
• Requesting Physician's State:
  (use 2-digit code)
• Requesting Physician's Zip:
• Requesting Physician's Email Address:
• Requesting Physician's Phone No:
• Requesting Physician's Fax No:*
• Servicing Physician's Name: *
• Servicing Physician's Specialty: *
• Servicing Physician's NPI: *
• Servicing Physician's Address: *
• Servicing Physician's City: *
• Servicing Physician's State: *
  (use 2-digit state code)
• 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: *
  (use 2-digit state code)
• Facility/Supplier Zip: *
• Facility/Supplier Phone Number: *
• Facility/Supplier Fax No: *

*** Please provide name of service or procedure to be performed as well as anatomical site. If spinal surgery, please provide level(s).

• New
• Replacement

• Other

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.

• Checking this box will send a copy of your form to the email address provided.