ICP Prior Authorization Form

Instructions:

Payment for services is dependent upon the patient's eligibility at the time services are rendered. Copays, coinsurance and/or deductibles may apply. Pre-certifications are valid for the date range specified on this form.


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Please fill out all fields with *

Request Type

Please select your type of request from the dropdown.

Authorization Processing Time

URGENT*CONCURRENT (IP)Decision will be rendered within 24 hours from receipt of all necessary information.
CONCURRENT (IP) Decision will be rendered within 72 hours from receipt of all necessary information.
URGENT* PRESERVICEDecision will be rendered within 72 hours from receipt of all necessary information.
PRESERVICE (Routine) Decision will be rendered within 15 calendar days from receipt of all necessary information.
POST SERVICE (Retro)Decision will be rendered within 30 calendar days from receipt of all necessary information.
[Post Service (Retro) requests are accepted up to 12 months from the date of service.]

*Urgent requests apply when: The PreService (routine) time frame could seriously jeopardize the life, health or ability to regain maximum function or subject the member to severe pain that cannot be managed without requested treatment.

Patient Information

Eligibility Verified?*

Future date is not available
Validation failed. Need 3 to 8 digits followed by SLHN in uppercase
Please fill out this field.

Servicing Provider Information

Provider Type?

Date should be after DOB
Date of service TBD

Please fill this field if referring practitioner in-network box is checked

Procedure Type?*

Facility/Company Information

Address same as servicing provider

Diagnosis CodeDiagnosis

Please fill out primary field.


Procedure CodeProcedure or EquipmentUnits

Please fill out primary field.



Available special characters are . , - / and space.

Attachments

*Attachment(s) is required

Please submit all supporting clinical documentation with request.

*Max file size is 10MB.

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HIPAA Notice: The information contained in this form may be confidential and legally privileged information. It is only for the use of individual or entity named above. If the recipient of this form is not the recipient addressed on the form, you are hereby notified that any dissemination, distribution or copying of the attached document(s) is strictly prohibited. If you have received this in error, please immediately notify the sender by telephone and return the form to the sender.

Org. 11/17 Rev.



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