OUTPATIENT OREGON HEALTHNET
MEDICARE AUTHORIZATION FORM
Expedited requests: Call 1-800-672-5941
Standard Requests: Fax to 1-844-692-4065
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Units
For Standard requests, complete this form and FAX to 1-844-692-4065. Determination made as
expeditiously as the enrollee’s health condition requires, but no later than
14 calendar days after receipt of request.
For Expedited requests, please CALL 1-800-672-5941. Expedited requests are made when the
enrollee or his/her physician believes that waiting for a decision under the
standard timeframe could place the enrollee’s life, health, or ability to regain maximum function in
serious
jeopardy.
*
INDICATES REQUIRED FIELD
MEMBER INFORMATION
Date of Birth
*
Member ID
*
Last Name, First
*
REQUESTING PROVIDER INFORMATION
Requesting NPI
*
Requesting TIN
*
Requesting Provider Contact Name
Requesting Provider Name
*
Phone
*
Fax *
SERVICING PROVIDER / FACILITY INFORMATION
Servicing NPI
*
Servicing TIN
*
Servicing Provider Contact Name
Servicing Provider / Facility Name
*
Phone
*
Fax
AUTHORIZATION REQUEST
Primary Procedure Code*
Additional Procedure Code*
Start Date OR Admisstion Date*
Diagnosis Code*
(CPT/HCPCS)
(Modifier)
(CPT/HCPCS)
(Modifier)
(MMDDYYYY)
(ICD-10)
Diagnosis Code*
Diagnosis Code*
Diagnosis Code*
Diagnosis Code*
(ICD-10)
(ICD-10)
(ICD-10)
(ICD-10)
Additional Procedure Code*
Additional Procedure Code*
End Date OR Discharge Date*
Total Units / Visits / Days
(CPT/HCPCS)
(Modifier)
(CPT/HCPCS)
(Modifier)
(MMDDYYYY)
OUTPATIENT SERVICE TYPE*
(Enter the Service type number in the boxes)
422 Biopharmacy
712 Cochlear Implants & Surgery
299 Drug Testing
922 Experimental Investigational Services
799 Genetic Counseling
709 Genetic Testing
249 Home Health
290 Hyperbaric Oxygen Therapy
395 Infertility Diagnosis or Treatment
712 Cochlear Implants & Surgery
299 Drug Testing
922 Experimental Investigational Services
799 Genetic Counseling
709 Genetic Testing
249 Home Health
290 Hyperbaric Oxygen Therapy
395 Infertility Diagnosis or Treatment
410 Observation
790 Occupational Therapy
997 Office Visit / Consult
794 Outpatient Services
171 Outpatient Surgery
202 Pain Management
101 Physical Therapy
701 Speech Therapy
992 Transplant
724 Transportation
792 Vendor
790 Occupational Therapy
997 Office Visit / Consult
794 Outpatient Services
171 Outpatient Surgery
202 Pain Management
101 Physical Therapy
701 Speech Therapy
992 Transplant
724 Transportation
792 Vendor
DME (Orthotics and Prosthetics)
417 Rental
120 Purchase
120 Purchase
(Purchase Price)
Disclaimer: An authorization is not a guarantee of payment. Member must be
eligible at the time services are rendered. Services must be a covered Health Plan Benefit and
medically necessary with prior
authorization as per Plan policy and procedures.
Confidentiality: The information contained in this transmission is confidential and may be protected under the Health Insurance Portability and Accountability Act of 1996. If you are not the intended recipient any use, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and destroy this document.
Confidentiality: The information contained in this transmission is confidential and may be protected under the Health Insurance Portability and Accountability Act of 1996. If you are not the intended recipient any use, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and destroy this document.
Rev 11 16 2017
XO-PAF-1650
XO-PAF-1650