Form WV-16-06-01 "Prior Authorization Form - Aetna" - Charleston, West Virginia

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Download Form WV-16-06-01 "Prior Authorization Form - Aetna" - Charleston, West Virginia

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Aetna Better Health® of West Virginia
500 Virginia Street East, Suite 400
Charleston, WV 25301
Prior Authorization Form
Fax to: 1-866-366-7008 Telephone: 1-844-835-4930
A determination will be communicated to the requesting provider.
Incomplete requests will delay the prior authorization process.
Please include pertinent chart notes to expedite this request.
TYPE OF REQUEST
URGENT
INPATIENT
(When a 7 calendar day non-urgent prior authorization could seriously jeopardize; the
life or health of a member, the member’s ability to attain, maintain, or regain maximum function,
OUTPATIENT
or that a delay in treatment would subject the member to sever pain that could not be adequately
managed without the are/service requested.)
HOME HEALTH CARE
NON-URGENT
(for routine services – response within 7 calendar days)
PATIENT INFORMATION
Patient Name:
Last
First
MI
Date of Birth:
/
/
I.D.#:
Gender:
EPSDT special service request?
M
F
Other Insurance?
Name of Carrier
Job Related?
MVA?
Is the member currently pregnant
YES
NO
YES
NO
YES
NO
YES
NO
FROM- REQUESTING PROVIDER
Requesting Provider (Please Print):
Tax ID#:
Contact Person in Requesting Provider’s
Telephone:
Fax:
WV Medicaid Provider #:
Office:
(
)
-
(
)
-
Clinical Contact Person:
Name of PCP:
Phone: (
)
-
TO- WHERE WILL PATIENT RECEIVE SERVICES?
Physician/Provider/Facility
Address:
Telephone:
Fax:
Requested:
(
)
-
(
)
-
Where services will be rendered? (Provide name of facility, if other than provider office or patient’s home)
WV Medicaid Provider #:
Today’s Date:
/
/
Tentative Date of Service/Admission:
/
/
Were member school based services interrupted?
Start Date:
/
/
YES
NO
End Date:
/
/
CLINICAL INFORMATION
ICD- 10 Codes: (required)
ICD- 10 Description:
1
2
3
4
CPT/HCPCS CODES: (required)
CPT/HCPCS Description:
1
2
3
4
Comments (list # Days/Visits/Units or if services are needed at discharge):
*DME, Therapies and Infusions must have Rx attached.*
CLINICAL INDICATIONS/RATIONALE FOR REQUEST:
To expedite a determination on your request for services, please attach clinical documentation/medical records to support your
request. Please include the following: Conservative treatment tried and failed, applicable diagnostic testing with results and lab
values and a medication list.
www.aetnabetterhealth.com/westvirginia
WV-16-06-01
Aetna Better Health® of West Virginia
500 Virginia Street East, Suite 400
Charleston, WV 25301
Prior Authorization Form
Fax to: 1-866-366-7008 Telephone: 1-844-835-4930
A determination will be communicated to the requesting provider.
Incomplete requests will delay the prior authorization process.
Please include pertinent chart notes to expedite this request.
TYPE OF REQUEST
URGENT
INPATIENT
(When a 7 calendar day non-urgent prior authorization could seriously jeopardize; the
life or health of a member, the member’s ability to attain, maintain, or regain maximum function,
OUTPATIENT
or that a delay in treatment would subject the member to sever pain that could not be adequately
managed without the are/service requested.)
HOME HEALTH CARE
NON-URGENT
(for routine services – response within 7 calendar days)
PATIENT INFORMATION
Patient Name:
Last
First
MI
Date of Birth:
/
/
I.D.#:
Gender:
EPSDT special service request?
M
F
Other Insurance?
Name of Carrier
Job Related?
MVA?
Is the member currently pregnant
YES
NO
YES
NO
YES
NO
YES
NO
FROM- REQUESTING PROVIDER
Requesting Provider (Please Print):
Tax ID#:
Contact Person in Requesting Provider’s
Telephone:
Fax:
WV Medicaid Provider #:
Office:
(
)
-
(
)
-
Clinical Contact Person:
Name of PCP:
Phone: (
)
-
TO- WHERE WILL PATIENT RECEIVE SERVICES?
Physician/Provider/Facility
Address:
Telephone:
Fax:
Requested:
(
)
-
(
)
-
Where services will be rendered? (Provide name of facility, if other than provider office or patient’s home)
WV Medicaid Provider #:
Today’s Date:
/
/
Tentative Date of Service/Admission:
/
/
Were member school based services interrupted?
Start Date:
/
/
YES
NO
End Date:
/
/
CLINICAL INFORMATION
ICD- 10 Codes: (required)
ICD- 10 Description:
1
2
3
4
CPT/HCPCS CODES: (required)
CPT/HCPCS Description:
1
2
3
4
Comments (list # Days/Visits/Units or if services are needed at discharge):
*DME, Therapies and Infusions must have Rx attached.*
CLINICAL INDICATIONS/RATIONALE FOR REQUEST:
To expedite a determination on your request for services, please attach clinical documentation/medical records to support your
request. Please include the following: Conservative treatment tried and failed, applicable diagnostic testing with results and lab
values and a medication list.
www.aetnabetterhealth.com/westvirginia
WV-16-06-01