Get the free Empire Blue Cross PRE-NOTIFICATION FAX FORM

This document is used for pre-notification of medical services to Empire Blue Cross, including patient details, service information, and physician contact.

How to fill out empire blue cross pre-notification

How to fill out Empire Blue Cross PRE-NOTIFICATION FAX FORM

1. Obtain the Empire Blue Cross PRE-NOTIFICATION FAX FORM from their official website or customer service.
2. Fill in the patient's personal information including name, date of birth, and member ID.
3. Provide the contact information of the healthcare provider, including name, phone number, and address.
4. Specify the type of service or procedure being requested for pre-authorization.
5. Attach any relevant medical documentation or notes that support the need for the service.
6. Double-check all entries for accuracy and completeness.
7. Sign and date the form where indicated.
8. Send the completed form via fax to the designated number provided by Empire Blue Cross.
9. Keep a copy of the sent fax and any supporting documents for your records.

Who needs Empire Blue Cross PRE-NOTIFICATION FAX FORM?

1. Patients who require prior authorization for certain medical services or procedures.
2. Healthcare providers submitting requests for pre-certification on behalf of their patients.
3. Individuals seeking coverage under Empire Blue Cross insurance plans.

For pdfFiller’s FAQs

What is Empire Blue Cross PRE-NOTIFICATION FAX FORM?

The Empire Blue Cross PRE-NOTIFICATION FAX FORM is a document that healthcare providers use to pre-notify the insurance company about proposed medical procedures or treatments that require prior approval.

Who is required to file Empire Blue Cross PRE-NOTIFICATION FAX FORM?

Healthcare providers or facilities that are planning to perform specific medical services or procedures requiring prior authorization from Empire Blue Cross are required to file the PRE-NOTIFICATION FAX FORM.

How to fill out Empire Blue Cross PRE-NOTIFICATION FAX FORM?

To fill out the Empire Blue Cross PRE-NOTIFICATION FAX FORM, providers need to include essential patient information, details about the medical service or procedure, and any relevant diagnostic codes, ensuring all sections are completed accurately.

What is the purpose of Empire Blue Cross PRE-NOTIFICATION FAX FORM?

The purpose of the Empire Blue Cross PRE-NOTIFICATION FAX FORM is to facilitate prior authorization for certain medical services, ensuring that the proposed treatment is medically necessary and covered under the patient's health plan.

What information must be reported on Empire Blue Cross PRE-NOTIFICATION FAX FORM?

The information that must be reported on the Empire Blue Cross PRE-NOTIFICATION FAX FORM includes patient name, identification number, provider details, the specific procedure being requested, the reason for the procedure, and supporting medical information or documentation.