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Iowa total care authorization form

Total care outpatient prior authorization form 2025

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The document is an Outpatient Medicaid Prior Authorization Fax Form used to request additional units of service. It outlines the process for standard and urgent requests, requiring specific member and provider information, procedure codes, service types, and clinical information. The form emphasizes the necessity of completing all required fields to avoid rejection and includes a disclaimer about authorization not guaranteeing payment.

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Click ‘Get Form’ to open the total care outpatient prior authorization form in the editor.
Begin by filling out the MEMBER INFORMATION section. Enter the Medicaid/Member ID, Date of Birth (MMDDYYYY), and the member's Last Name and First Name. Ensure all required fields marked with an asterisk (*) are completed.
Next, move to the REQUESTING PROVIDER INFORMATION section. Fill in your Requesting NPI, Contact Name, TIN, and Provider Name. Don’t forget to include your Fax and Phone number.
If applicable, provide SERVICING PROVIDER / FACILITY INFORMATION. If it’s the same as the requesting provider, check the box provided; otherwise, fill in the Servicing NPI, Contact Name, TIN, Provider/Facility Name, Fax, and Phone.
In the AUTHORIZATION REQUEST section, enter the Primary Procedure Code and any Additional Procedure Codes along with their Modifiers. Specify the Outpatient Service Type by entering its corresponding number.
Complete the Start Date or Admission Date and Diagnosis Code fields. Finally, indicate Total Units/Visits/Days required for authorization.

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2019	4.8 Satisfied (175 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the fax number for Absolute Total Care prior authorization?

Our fax number is 1-844-503-8866. Please note: faxes will not be monitored after hours and will be responded on the next business day. Please contact our 24/7 Nurse Advice Line at 1-855-735-4398 for after hour urgent admissions or inpatient notifications or requests.

What is a pre-authorization phone number?

A number, code, or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also called Prior Authorization or Referral Number).

What is the phone number for select health prior authorization?

For items on the list below, access online preauthorization forms (there are separate forms for medical and psychological services and for services related to substance use). Questions? Contact Member Services at 800-538-5038.

How to obtain prior authorization?

The Prior Authorization Process Flow The healthcare provider must check a health plans policy or prescription to see if Prior Authorization is needed for the prescribed treatment. The healthcare professional must sign a Prior Authorization request form to verify the medical necessity claim.

Does Iowa Total Care require prior authorization?

Some services require prior authorization from Iowa Total Care in order for reimbursement to be paid to the provider. Check to see if a prior authorization is necessary by using our online tool. Prior authorization must be obtained prior to the delivery of certain elective and scheduled services.

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What is the phone number for Absolute Total Care prior authorization?

1-866-912-3606 Complete and Fax to: ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED. COPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED.

What is the phone number for eviCore prior authorization form for radiology?

eviCore healthcares prior authorization call center is available from 8:00 a.m. to 9:00 p.m. Eastern Standard Time, Monday through Friday. The phone number is (888) 693-3211.