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

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* 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: *
  • IDC-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)
  • 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.
  • 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 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: *

Proposed Intervention: *

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

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.

If you have questions, contact Blue KC at (816) 395-3989.

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IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

ID Number

Your member ID is a unique number that identifies your plan. It is on the front of 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.

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.

For Blue Card members, suffix is not required.

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