WoundReference improves clinical decisions
 Choose the role that best describes you
WoundReference logo

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


HOSPITAL TAX ID: __________________


Patient: ____________________________________        Date of Birth: ______________________

Home Phone: _______________________________        Work / Cell Phone: ________________________


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

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

HBO Physician: _____________________________ NPI__________________________________

Protocol: ______________________________ Anticipated Treatments: ___________________


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________________________


Official reprint from WoundReference® woundreference.com ©2021 Wound Reference, Inc. All Rights Reserved
Use of WoundReference is subject to the Subscription and License Agreement. ​
NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.
Topic 925 Version 1.0