Pre-authorization Request Form

*Asterisks indicate required fields.


Use this form to submit standard pre-authorization requests for:

  • Transplants
  • Behavioral health services
  • Outpatient medical services
  • DME and professional services
  • Inpatient and outpatient surgeries
  • Skilled nursing, long term acute care, inpatient rehabilitation

Do NOT use this form to submit expedited requests

Expedited is defined as: when the member or his/her physician believes that waiting for a decision under the standard time frame could place the member's life, health, or ability to regain maximum function in serious jeopardy.

To submit an expedited request, please fax our request form to the dedicated number shown to the right.

 

Expedited requests

Fax our Request form (PDF) to:

  • Commercial and Medicare: 1 (855) 240-6498
  • ASO and UMP: 1 (844) 679-7764

Instructions: This form should be filled out by the provider requesting the service or DME. Please complete all applicable fields. Prior to completing this form, please confirm the patient’s benefits, eligibility and if pre-authorization is required for the service. To determine if pre-authorization is required, please go to the provider website or call the phone number on the back of the member’s card.  
   
Have you verified if pre-authorization is required?  
Yes
No  [Note: If no, please verify with the pre-authorization list or call the number on the back of the member’s card.]
 
Is this request for a pre-service benefit organization determination?  
Yes
No
 
Is this request:  
New
Authorization Extension
Providing Additional Information
Medicare Only - Preservice Benefit Organization Determination Request
Expedited (STOP - do not use this form to submit expedited requests. Please fax our Requst form (PDF) to our dedicated fax number)
 
     

Requested changes to existing request

 

   
     
 

Section I - Patient Information

Please enter patient information:
     
Patient last name:*
 
Patient first name:*
 
Patient middle initial:
 
Patient DOB:*
MM/DD/YY
Patient's Regence member ID:*
ID number from member card
Patient's Regence Group Number:*
Group number from member card
Patient phone:* Include area code

Section II - Provider Information

Please enter provider information:    
 
 
Requesting Provider  
Rendering Provider  
DME Supplier  
Provider name:*
Last, First, MI
Provider specialty:*  
Tax ID number:*
 
NPI number:*

 

Phone number:*
 
Confidential voicemail?*
Yes No  
FAX number:*
 
Provider street address:*
 
City, State, Zip:*
 
Who should we contact if we require additional information?    
Contact Name:*
 
Contact Phone:*
Include extension if applicable
Confidential Voice Mail:*
 
Contact Fax:*
 
Email:*
 
     

Section III - Pre-authorization Request
     
Is this request*:    
Pre-Service    
Concurrent Review    
     
Date of Service (if scheduled): MM/DD/YY
     
 
  Inpatient  
  ASC  
   
  Other  
     
Please check all that apply:
  Diagnostic  
  Medical  
  DME  
 
     

Physical  address where service will occur:    
Rendering or Treating Provider:
Last, First
Street address:
Address where service will occur
Street address line 2:
 
City, State, Zip:
 
     

Inpatient/outpatient hospital request:    
Facility name:
 
Anticipated admission date (if scheduled)/Start date of treatment:
MM/DD/YY
Anticipated length of stay:
 
   

Note: If anticipated length of stay is not indicated no more than two days will be assigned if approved.

Note: This request form does not serve as a notification of admission. Please reference the provider website for instructions to notify us of an admission.

 
     

DME request:      
   
Company name:
 
   
Tax ID number:
 
   
NPI number:
 
   
DME Street address:
 
   
Street address line 2:
 
   
City, State, Zip:
 
   
Telephone number:
 
   
Fax number:
 
 
DME - Signed copy of prescription faxed?:
Yes  No  
 
DME - Invoice faxed?:
Yes  No  
 

Please provide all diagnosis, CPT® or HCPCS codes and their descriptions, if available; this will help processing of your request.  
  Diagnosis code or description* CPT or HCPCS code
or description*
DME Only-
Line Item Cost
Primary
diagnosis:
Secondary diagnosis:
Third
diagnosis:
     

Please fax the following clinical information, as appropriate for this request:
  • History & Physical
  • Treatment history
  • Laboratory/radiology/testing results
  • Current symptoms & functional impairments
  • Any other information such as chart notes that support medical necessity
 
     

If you prefer, you may print and fax a completed Pre-authorization Request Form (PDF) with supporting documentation to 1 (855) 207-1209.