Precertification Request Form for Empire BlueCross BlueShield
The Precertification Request Form for Empire BlueCross BlueShield helps streamline prior authorization processes. Fill out this form with all necessary details and fax it to Empire. Ensure all applicable information is included to prevent delays.
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How do I fill this out?
To fill out the Precertification Request Form, start by gathering all necessary member and provider information. Next, accurately complete each section of the form. Finally, fax the completed form to the specified Empire contact number.
How to fill out the Precertification Request Form for Empire BlueCross BlueShield?
1
Gather member and provider information.
2
Complete the member information section.
3
Fill in the referring provider section.
4
Include service details and codes.
5
Fax the completed form to Empire.
Who needs the Precertification Request Form for Empire BlueCross BlueShield?
1
Healthcare providers needing prior authorization for services.
2
Facilities requesting approval for long-term care services.
3
Medical equipment suppliers seeking authorization for durable medical equipment.
4
Home healthcare agencies requesting approval for home care services.
5
Nursing facilities needing prior authorization for patient admissions.
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What are the instructions for submitting this form?
Submit the completed Precertification Request Form as follows: For outpatient services, fax to 1-855-201-8530. For durable medical equipment, fax to 1-855-201-8527. For home care, fax to 1-855-201-8528. For long-term services and supports, fax to 1-844-528-3685. For skilled nursing facility, fax to 1-844-879-2964. For long-term custodial care, fax to 1-888-826-9591. Ensure that all required details are accurately filled to prevent delays in processing.
What are the important dates for this form in 2024 and 2025?
Ensure to submit the form for any planned services as soon as possible in 2024 and 2025 to avoid any delays in processing.
What is the purpose of this form?
The purpose of the Precertification Request Form is to streamline the prior authorization process for various medical services. It helps healthcare providers, facilities, and agencies obtain necessary approvals efficiently. Accurate completion of this form ensures timely authorization and prevents delays in patient care.
Tell me about this form and its components and fields line-by-line.
- 1. Member Information: Includes fields for member's name, Empire ID, phone, address, and date of birth.
- 2. Provider Return Fax: Field for the provider's return fax number.
- 3. Referring Provider: Requires the referring provider's name, NPI, provider ID, specialty, and contact details.
- 4. Servicing Provider: Includes fields for the servicing provider's name, provider ID, and contact information.
- 5. Servicing Facility: Requires details for the servicing facility including name, provider ID, and contact information.
- 6. Requested Service: Section for ICD-10 and CPT codes, type of service, and date range.
- 7. Additional Information: Field for any additional information relevant to the request.
What happens if I fail to submit this form?
Failure to submit this form can result in delays or denial of prior authorization for medical services. Ensure the form is complete and submitted to avoid issues.
- Delays in Processing: Incomplete forms can delay the authorization process, affecting patient care.
- Denial of Service: Failure to obtain prior authorization can lead to denial of requested medical services.
- Financial Impact: Lack of authorization may result in additional costs for the patient or provider.
How do I know when to use this form?
- 1. Outpatient Services: Use for services rendered on an outpatient basis.
- 2. Durable Medical Equipment: Use for requesting authorization for medical equipment.
- 3. Home Care: Request prior authorization for home healthcare services.
- 4. Long-term Care: Use for requesting services related to long-term care.
Frequently Asked Question
What is the purpose of the Precertification Request Form?
The form is used to request prior authorization for various medical services from Empire BlueCross BlueShield.
How do I fill out the member information section?
Include the member's name, Empire ID, phone number, address, and date of birth.
What details are needed for the referring provider section?
Provide the referring provider's name, NPI, provider ID, specialty, and contact information.
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Upload the form to PrintFriendly, open it in the PDF editor, make your edits, and save your changes.
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Use the PDF editor on PrintFriendly to insert your digital signature in the required fields.
Can I share the completed form electronically?
Yes, use the share option on PrintFriendly to send the form via email or generate a shareable link.
What happens if I don't fill out all sections of the form?
Incomplete forms may result in delays in processing your prior authorization request.
Which services require prior authorization using this form?
Prior authorization is required for outpatient services, durable medical equipment, home care, long-term care, and more.
How do I submit the completed form to Empire?
Fax the completed form to the specified Empire contact number for the service you are requesting.
What should I do if I need help filling out the form?
Contact Empire BlueCross BlueShield for assistance with any questions about the form.
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