Out-of-area/network providers resources
Below are several forms commonly used by providers.
To help simplify your administrative tasks, you may download and print these forms.
Preauthorization request forms
- Home health fax form - Home health skilled nursing and/or therapy visit treatment (at home).
- Hospice fax form
- Inpatient elective fax form - Non-urgent/emergent inpatient admissions.
- Letter of medical necessity fax form - To be used when a letter of medical necessity is required for specified services also can be used by PCP is requesting authorization review for out-of-network/out-of-area services for a managed care patient.
- Power wheelchairs, power operated vehicles (POV) and related options and accessories preauthorization form
- Prior authorization modification and date extension request form
- Transplant fax form
- Therapy fax form - Initial evaluation/treatments for physical therapy or occupational therapy (non-managed care products i.e. HMO).
Preauthorization specialty injectable forms (non-Medicare plans)
- Antiemetic drugs preauthorization request form
- Botulinum toxin preauthorization request form
- Colony stimulating factors preauthorization request form
- Denosumab oncology (Xgeva®) preauthorization request form
- Healthcare provider administered biologic immunomodulators preauthorization request form
- IV multiple sclerosis drugs preauthorization request form
- Injectable oncology agents preauthorization request form
- Medical injectable drugs (non-drug specific) preauthorization request form
- Onasemnogene abeparvovec-xioi (Zolgensma®) preauthorization request form
- Oncology immunotherapy agents preauthorization request form
- Xolair® (Omalizumab) preauthorization request form
For services authorized via our musculoskeletal services provider
If the CPT code is listed on the single source preauthorization list and indicates authorization via our musculoskeletal services provider, the following will apply.
Musculoskeletal services post service review process
Please follow the process below for post service surgical reviews:
- Provider has received an authorization for requested CPT code(s).
- Following the procedure, the CPT code has changed due to performed surgical procedure:
- CPT code was added to the approved code or instead of the approved code(s).
- Operative note is required for verification of the additional procedure code(s).
Complete the post-service claim review form.
- Fill in each section, especially the box indicating the update reason.
- Example: Approval was for CPT 29880 and during surgery, CPT code 29881 was performed.
Fax the following information to our musculoskeletal services provider at 717.412.1001.
- Cover sheet with provider information, including contact name and phone number.
- Completed post-service claim review form.
- Operative note: Please make sure the member’s name is listed.
Our musculoskeletal services provider will review the faxed information and make a determination within 7-10 business days.
- Our musculoskeletal services provider will notify the provider of the post service determination.
- Our musculoskeletal services provider will notify us of the determination.
- We will verify our records and perform any adjustments, if applicable.
If our musculoskeletal services provider denied the entire surgical request and the procedure was performed, it does not constitute a post service review.
- Provider can appeal the denied determination.