Authorization Review Form for Health Care Services
Marketplace
MEDICAL SERVICES
Pre-Authorizations Fax: 713.295.7019
Admission Notifications Fax: 713.295.2284
IP Concurrent Review Fax:
713.295.7030 or 1.844.899.2496
BEHAVIORAL HEALTH SERVICES
Pre-Authorization OP Fax: 713.576.0930
Pre-Authorization IP Fax: 713.576.0932
URGENT REQUESTS: 713.295.6704
Medicaid/CHIP
MEDICAL SERVICES
Pre-Authorizations Fax:
713.295.2283 or 1.844.899.2495
Admission Notifications Fax:
713.295.2284 or 1.844.831.8323
IP Concurrent Review Fax:
713.295.7030 or 1.844.899.2496
BEHAVIORAL HEALTH SERVICES
Pre-Authorizations OP Fax: 713.576.0931
Pre-Authorizations IP Fax: 713.576.0932
URGENT REQUESTS: 713.295.2295
HMO D-SNP
MEDICAL SERVICES
Pre-Authorizations Fax: 713.295.7059
BEHAVIORAL HEALTH SERVICES
Pre-Authorization OP/IP Fax: 713.576.0939
URGENT REQUESTS: 713.295.5007
Providers must submit the Prior Authorization Request Form. The form must include the
following information:
• Member Name
• Member Date of Birth
• Member Medicaid/CHIP
Identification Number
• Requesting Provider Name and National
Provider Identifier (NPI)
• Servicing Provider Name and NPI
• Quantity of service units requested based on
the CPT, HCPCS, or CDT requested
• Requesting Provider’s signature and date
• Requested Service
o Current Procedural Terminology
(CPT) Codes
o Healthcare Common Procedure
Coding System (HCPCS), or
o Current Dental Terminology (CDT)
o Service requested start and end
date(s)
Please note any prior authorization requests missing information will not be processed and a
new request will need to be submitted.
For additional information, please visit our website at https://
provider.communityhealthchoice.org/resources/prior-authorization-information/
Failure to Complete All Applicable Fields May Delay Processing
SECTION I —SUBMISSION
Issuer Name: Phone: Fax: Request Date:
SECTION II — GENERAL INFORMATION
Review Type:
Non-Urgent
Urgent
Clinical Reason for Urgency:
Request
Type:
Initial Request
Extension
Amendment
Prev. Auth. #:
Inpatient
Outpatient
Provider Oce
Observation
Home
Day Surgery Other:___________________________
SECTION III - PATIENT INFORMATION
Name: Phone: DOB:
Male
Female
Other
Unknown
Subscriber Name (if dierent): Member or Medicaid ID #: Plan Name:
SECTION IV - PROVIDER INFORMATION
Requesting Provider or Facility
Name: Tax ID:
NPI #: Specialty:
Phone: Fax:
Contact Name: Phone:
Requesting Provider’s Signature and Date:
SECTION V - SERVICES REQUESTED (with CPT, CDT, REV or HCPCS code) and supporting diagnoses (with ICD CODE)
Physical Therapy
Occupational Therapy
Speech Therapy
Cardiac Rehab
Mental Health/Substance Abuse
Home Health (MD Signed Order Attached?)
Yes
No Nursing Assessment Attached?
Yes
No
DME (MD Signed Order Attached?)
Yes
No Title 19 Certication Attached? (Medicaid Only)
Yes
No
Equipment/Supplies (include any HCPCS Codes):
Yes
No Duration: ________________
Other Services: ______________________________________________________________________________________________
Planned Service or
Procedure
Code (CPT, HCPCS,
Revenue Code)
Units Start Date End Date Diagnosis Description ICD-10
Code
An issuer needing more information may call the requesting provider directly at: ___________________________
** Required: Attach clinical documentation to this form upon submission.**
Service Provider or Facility
Name: Tax ID:
NPI #: Specialty:
Phone: Fax:
Primary Care Provider Name (see instructions):
Phone: Fax: