Personal Care Work Services (PCW) Prior Authorization Fax Form Please complete all fields on the form and fax to: 866-273-2240 SECTION I — PROVIDER INFORMATION 1. Check request type 2. Process Type Routine 3. Telephone/Fax Number ― Billing Provider Urgent (urgent is defined as “significant impact to health of the member”) Phone: Initial request Re-certification request 4. Name and Address — Billing Provider (Street, City, State, ZIP+4 Code) Fax: 5a. Billing Provider Tax ID Number (TIN) 5b. Billing Provider Taxonomy Code (if available) 6a. Name — Prescribing / Referring / Ordering Provider 6b. National Provider Identifier — Prescribing / Referring / Ordering Provider SECTION II — MEMBER INFORMATION 8. Date of Birth — Member 7. Member Identification Number 10. Name — Member (Last, First, Middle Initial) 9. Address — Member (Street, City, State, ZIP Code) 11. Gender — Member Male Female SECTION III — DIAGNOSIS / TREATMENT INFORMATION 12. Diagnosis — Primary Code and Description 13. Start Date — SOI 15. Diagnosis — Secondary Code and Description 16. Requested PA Start Date 17. Rendering Provider Number 18. Rendering Provider Taxonomy Code 19. Service Code 20. Modifiers 1 2 T1019 T1019 3 21. POS 14. First Date of Treatment — SOI 22. Description of Service 23. QR 24. Charge 4 12 U3 99509 12 12 An approved authorization does not guarantee payment. Reimbursement is contingent upon enrollment of the member and provider at the time the service is provided and the completeness of the claim information. Payment will not be made for services initiated prior to approval or after the authorization expiration date. In order to process your request completely and timely, submit any pertinent clinical data ( i.e. progress notes, treatment rendered, tests, to support request for services. Any request for OON services must include documentation on the reason for the request along with the name of the OON provider. FAILURE TO PROVIDE SUFFICIENT INFORMATION W ILL RESULT IN A DELAY IN YOUR REQUEST . 25. Total Charges 26. SIGNATURE — Requesting Provider 27. Date Signed Coverage provided by UnitedHealthcare of Wisconsin, Inc.
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