Fidelis Care Prior Authorization Request Form 2018 free printable template

Prior Authorization Request Form Required for: MetalLevel Products, Managed Medicaid, CHP, and Medicare AdvantageFax: (800) 8608720Fidelis Care Member Name (Last, First, M.I.):Questions: (888) 3433547Member

How to fill out

How to fill out Fidelis Care Prior Authorization Request Form

1. Obtain the Fidelis Care Prior Authorization Request Form from the Fidelis Care website or your healthcare provider.
2. Fill in the patient's personal information, including name, date of birth, and insurance ID number.
3. Provide the details of the requesting provider, including name, contact information, and NPI number.
4. Specify the requested service or procedure, including codes and descriptions.
5. Include relevant clinical information and medical necessity documentation to support the request.
6. Sign and date the form, and ensure all required fields are completed.
7. Submit the form through the designated channel (fax, online submission, or mail) as instructed.

Who needs Fidelis Care Prior Authorization Request Form?

1. Individuals seeking specific medical treatments or services covered by Fidelis Care that require prior authorization.
2. Healthcare providers requesting approval for procedures or services on behalf of their patients.

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What is Fidelis Care Prior Authorization Request Form?

The Fidelis Care Prior Authorization Request Form is a document that healthcare providers use to request approval for specific medical services or treatments before they are provided to members.

Who is required to file Fidelis Care Prior Authorization Request Form?

Healthcare providers or practitioners who are proposing services or treatments that require prior authorization must file the Fidelis Care Prior Authorization Request Form.

How to fill out Fidelis Care Prior Authorization Request Form?

To fill out the Fidelis Care Prior Authorization Request Form, providers should enter patient information, the requested service or treatment details, clinical information supporting the request, and any necessary attachments.

What is the purpose of Fidelis Care Prior Authorization Request Form?

The purpose of the Fidelis Care Prior Authorization Request Form is to ensure that certain medical services and treatments are medically necessary and covered under the member's insurance plan before they are performed.

What information must be reported on Fidelis Care Prior Authorization Request Form?

The information that must be reported on the Fidelis Care Prior Authorization Request Form includes patient demographics, service requested, diagnosis codes, treatment plan, and supporting medical documentation.