Request for Services Requiring Pre Authorization
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PROVIDER HANDBOOK - Clear Health Alliance - …
www.clearhealthalliance.comPage 2 of 92 Prov Hand CHA January 2013 Dear Provider: Please allow us to extend a personal greeting in welcoming you to Clear Health Alliance. Attached you will find your Clear Health Alliance, Inc. (CHA) Provider Handbook that has
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passporthealthplan.comPage 6 of 8 DME items with billable charges greater than $500 require an authorization. Requests for authorization of purchase MUST be received PRIOR to …
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PLEASE READ CAREFULLY THE FOLLOWING …
www.wcb.ny.govThe undersigned requests written authorization for the following special service(s) costing over $1,000 or requiring pre-authorization pursuant to the Medical Treatment Guidelines.Do NOT use this form for injuries/illnesses involving the Mid and Low Back, Neck, Knee, Shoulder, Carpal Tunnel Syndrome and Non-Acute Pain, except for the …
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