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Provider materials and tools
Find important fax numbers
Please do not fax to multiple fax numbers, this may impact our response time.
- Request for services requiring prior authorization & authorization status
- Signed Single Case Agreement (SCA) forms
- Requests for retrospective/post service review
- Medical records (not pertaining to a current admission or an appeal)
- Initial notification of emergency inpatient hospital admissions with clinical information
- Initial notification of emergency inpatient observation days
- All subsequent clinical information for on-going concurrent review
Medical records and corresponding appeal summaries
- Clinical Medical Necessity Denial appeals (must be the result of an Adverse Benefit Determination (ABD) formerly Notice of Action (NOA))
- Administrative Denial Appeals (must be the result of a NOA)
- Claim denials for 45-day Inpatient Benefit Exhaustion (BBA)
- Claim denials for Provider Preventable Condition reviews
Care integration, communication tools and documents
- Case Management referrals and inquiries
- Provider administered Health Risk Assessments (HRAs)
- Family member or Provider administered Consent to Release Protected Health Information (PHI)
- Power of Attorney or other legal documents