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HBO Pre-Determination/ Prior Authorization

HBO Pre-Determination/ Prior Authorization

HBO Pre-Determination/ Prior Authorization

Instructions: Below is a template for prior authorization from Non-Medicare Carriers for Hyperbaric Oxygen Therapy treatment, which can be adapted to fit your needs. A fillable PDF is attached for your convenience. Prior to use, ensure the adapted version is reviewed and approved by responsible parties within the HBO clinic/hos

pital.


HOSPITAL TAX ID: __________________

PATIENT DEMOGRAPHICS

Patient: ____________________________________        Date of Birth: ______________________

Home Phone: _______________________________        Work / Cell Phone: ________________________

REQUESTED SERVICES   

99183          G0277   (# of 30-minute Increments)  _____________

ICD-10 Code 1: ______________  ICD-10 Code 2:______________

HBO Physician: _____________________________ NPI__________________________________

Protocol: ______________________________ Anticipated Treatments: ___________________

INSURANCE 

Primary: ___________________________¬______ Secondary: _______________________________

Policy #: ___________________________¬______ Policy #: _________________________________

Group #: _________________________________ Group #: _________________________________

Subscriber: _______________________________ Subscriber: _______________________________

Relationship to patient: ______________________ Relationship to patient: ______________________

Insurance Phone ____________________________        Insurance Representative_________________________

Insurance Effective Date:_______________                     Hyperbaric Benefits:  Yes    No

Deductible   Yes   No  Deductible Amount_________________ Deductible Met 

Co-payment   Yes   No Co-payment Amount________________(specify amount or percent)

Authorization Required  Yes   No Predetermination Required   Yes    No

Authorization Number _______________________________________________________________________________

Authorization Date Range: ___________________________ Number of visits Authorized________________________

Authorization Number _______________________________________________________________________________

Authorization Date Range: ___________________________ Number of visits Authorized________________________

Comments:


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Topic 925 Version 1.0