Submitting Requests for Prior Authorization
Requests outside of this definition should be submitted as routine/non-urgent. Referral/Service Type Requested. Inpatient ☐Surgical procedures ☐Admission ☐SNF ☐Rehab ☐LTAC. Outpatient ☐Office Visit ☐Rehab (PT, OT, & ST) ☐Surgical Procedure ☐Wound Care ☐Diagnostic Procedure☐Infusion Therapy ☐DME ☐ Other: ... ................
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