Fidelis CarePrior Authorization Request Form Prior Authorization Request Form 2026

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The document is a Prior Authorization Request Form required for specific health insurance products, including Metal-Level Products, Managed Medicaid, CHP, and Medicare Advantage. It outlines the necessary information to be provided by the member and servicing providers, including diagnosis codes, procedure details, and clinical information needed for authorization. The form must be completed in full and submitted via fax to obtain service determination within regulatory timeframes.

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Click ‘Get Form’ to open the Fidelis Care Prior Authorization Request Form in the editor.
Begin by entering the member's information, including their name, ID number, and date of birth. Ensure accuracy as this information is crucial for processing.
In the 'Services' section, input the ICD-10 Diagnosis Code(s) and CPT/Procedure Code(s) along with a brief description. This helps clarify the medical necessity of the request.
Check any applicable boxes for Medicare, Workers' Comp, or No-Fault claims. Provide dates for injury and procedure if relevant.
Fill in details about the servicing provider, including their name, phone number, address, Tax ID, and NPI. This ensures that all communications are directed correctly.
Indicate whether this request is urgent or pertains to inpatient/outpatient services by checking the appropriate boxes.
Complete any additional information required and check all clinical documents you are submitting with this form to support your request.
Once completed, fax the form to 1-800-860-8720 as instructed. You will receive notification regarding 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.

How to obtain prior authorization?

How To Get Prior Authorization: Step-by-Step Guide Step 1: Check client eligibility. Step 2: Determine if a code or service requires Prior Authorization. Step 3: Find and complete forms. Step 4: Submit a PA request. Step 5: Check the status of an authorization.

Can I initiate my own prior authorization?

Some plans allow patients to file their own prior authorizations, but most often this is a process that must be initiated with the doctors office. Often your doctor will have an idea that the healthcare you need is likely to require this extra step.

Can you fill out your own prior authorization?

To get prior authorization Call your insurance company before you receive your health care services or prescription. Discuss the health care services or prescription that you need and ask if prior authorization is required. If you need prior authorization, ask about the specifics.

How to get a prior authorization form?

To receive coverage for a medication requiring prior authorization, you can: Ask your healthcare provider to submit the request. Your healthcare provider can submit the request online, by fax or phone by accessing our providers prior authorization information. Submit your own prior authorization request.

What is the number for prior authorization for Fidelis?

All Prior Authorizations can be submitted online, except the following: Must be submitted via the appropriate fax line or by phone at 1-888-FIDELIS (1-888-343-3547):