Programs Prior Authorization Request Form

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Indiana Health Coverage Programs Prior Authorization ...

www.in.gov

IHCP Prior Authorization Request Form Version 6.2, May 2021 Page 1 of 1 Indiana Health Coverage Programs Prior Authorization Request Form Fee-for-Service Gainwell Technologies P: 1-800-457-4584, option 7 F: 1-800-689-2759

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Benefit Prior Authorization - BCBSIL

www.bcbsil.com

Benefit Prior Authorization 2020 ... Programs – Blue Cross Medicare Advantage and Blue Cross Community Health Plans – members, refer to the ... Predetermination of benefits may be requested by using the Predetermination Request Fax Form located in the

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PATIENT PANO Service Request Form - Novartis

www.patient.novartisoncology.com

Patient Authorization – Required for Processing Fax Number: 1-888-891-4924 Complete the patient PANO (Patient Assistance Now Oncology) Service Request Form to find out if you qualify for Novartis Oncology programs that may provide financial support and free trial offers.

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Prior Authorization of Sleep for Blue Cross and Blue Shield

www.evicore.com

Prior authorization applies to services that are: •Outpatient •Elective / Non-emergent eviCore Prior authorization does not apply to services that are performed in: • Emergency room • Inpatient • 23-hour observation It is the responsibility of the ordering provider to request prior authorization approval for services.

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Prior Authorization of Radiology/Cardiology for Fidelis Care

www.evicore.com

Prior authorization does not apply to services that are performed in: • Emergency room Inpatient • 23-hour observation It is the responsibility of the ordering provider to request prior authorization approval for services. It is the responsibility of the performing facility to confirm that the referring physician

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Repetitive, Scheduled Non-Emergent Ambulance Transport ...

www.cms.gov

Dec 01, 2015 · A provisional affirmative prior authorization decision affirms a specified number of trips within a specific amount of time. The prior authorization decision, justified by the beneficiary’s condition, may affirm up to 40 round trips (which equates to 80 one-way trips) per prior authorization request in a 60-day period.

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Procedures, programs, and drugs that require precertification

member.aetna.com

Or, they can fax applicable request forms to 1-877-269-9916. • Your provider can use the drug-specific Specialty Medication Request Form located online under “Specialty Pharmacy Precertification.” • Your provider can submit Specialty Pharmacy precertification requests electronically using provider online tools and

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