Transcription of HUMANA Pain Management Prior Authorization Request …
1 HUMANA pain ManagementPrior Authorization Request Form** Please complete and Fax this Request form along with all supporting clinical documentation to OrthoNet at 1-888-605-5345. NOTE: The information transmitted is intended only for the person or entity to which it is addressed and may contain CONFIDENTIAL material. If you receive this material/information in error, please contact the sender and delete or destroy the For Internal Office Use OnlyRev. 4/1/2014 Copyright 2014 OrthoNet, LLCPATIENT INFORMATION: HUMANA Member ID NumberMonthDayYearDate of Birth//Last NameFirst Name(Must be completed in order to process Request )3. Please provide exact Epidural Levels or facet Joint Levels or exact Medial branch Nerves to be injected RightLeftBilateralEpidural Steroid Injection facet Joint Injection2.
2 Requested Procedure(s):TrialImplantSpinal Cord Stimulator:Trial (Narcotic - Baclofen - Prialt)Implant (Narcotic - Baclofen - Prialt) pain Pump: facet Medial branch Nerve block :LocalSteroidRFA1. Primary Diagnosis CodeCervicalThoracicLumbarSacralPlease Select Spinal Region(s) which applies: If yes, ____% pain Relief lasted ____ weeks from last (Epidural or facet injection) performed on Date:_____YesNo4. Previous Epidural or facet Injections(s)?CPT Code(s):Anticipated Date of Service(s)//MonthDayYearRequested Facility for Surgery/Procedure(s)(If Applicable)StateCityFacility Tax ID NumberPROVIDER INFORMATION:Fax Date://(including this cover page)Number of pages faxed :Street AddressProvider NameCityStateZIPF acility NPI NumberIndividual NPI NumberNational Provider Identifier (NPI)Facility Tax ID NumberIndividual Tax ID NumberProvider Tax ID NumberFax Number()-Telephone Number()-2100621006
