Fidelis CarePrior Authorization Request Form Prior Authorization Request Form 2025

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The document is a Prior Authorization Request Form required for various health insurance products, including Metal-Level Products, Managed Medicaid, CHP, and Medicare Advantage. It outlines the necessary information and clinical documentation needed to request authorization for medical services, including member details, diagnosis codes, procedure codes, and provider information. The form must be completed in full and submitted via fax to receive a service determination within the regulatory timeframe.

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Got questions?

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 phone number for Fidelis provider prior authorization?

If you have any additional questions regarding the self-service authorization status process, please contact our Provider Call Center at 1-888-FIDELIS (1-888-343-3547) or your local Provider Relations Specialist.

Why is my insurance asking for a prior authorization?

Insurance providers use prior authorization to make sure that a specific medical service is needed and worth the cost, and that no duplicative services are being performed. Payers use prior authorization as a way to keep healthcare costs in check.

What does a prior authorization form do?

PAs are used by Medi-Cal to help ensure that necessary medical, pharmacy, or dental services are provided to Medi-Cal recipients and that providers are reimbursed appropriately. PAs are confidential documents and the information included on them is protected by state and federal privacy laws.

What is a pre-authorization form used for?

Prior authorization requires your doctor or provider to obtain approval from your health plan before providing health care services or prescribing prescription drugs. Without prior authorization, your health plan may not pay for your treatment or medication. (Emergency care doesnt need prior authorization.)

What is a prior authorization request form?

Prior authorization also frequently referred to as preauthorization is a utilization management practice used by health insurance companies that requires certain procedures, tests and medications prescribed by healthcare clinicians to first be evaluated to assess the medical necessity and cost-of-care ramifications

Who handles submitting a request for prior authorization?

to the insurer: Patient name, date of birth, insurance policy number, and other relevant information. Physician and facility information (eg, name, provider ID number, and tax ID number) Relevant procedure and HCPCS codes for products/services to be provided/performed.

Who requires a prior authorization?

Prior authorizations are usually only required for more costly, involved treatments where an alternative is available. For instance, if a physician prescribes an invasive procedure such as orthopedic surgery, it will likely require preauthorization.

Fidelis CarePrior Authorization Request Form Prior Authorization Request Form 2025

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