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Hospice Auth Request Form
*Indicatesa required field
Requirements: Clinical information and supportive documentation should consist of current physician order, notes and recent diagnostics. Notification is required for any date of service change. Expedited Requests: If the standard time for making a determination could seriously jeopardize the life and/or health of the member or the member's ability to regain maximum function, please call Staywell at 1-866-334-7927 or CMS Health Plan at 1-866-799-5321
Fax completed form to: (855)-657-8641 Requestor Name: __________________________ Fax*: ________________________ Phone*:_________________________
WellCare ID*: Last Name*:
MEMBER INFO (Please Print) Medicaid/Medicare ID:
First Name, MI*: REQUESTING PROVIDER
First Name, MI*: Date of Birth*: / /
WellCare ID: Provider Name*: City, State, ZIP:
WellCare ID:
NPI/Tax ID*: Address: Fax*: HOSPICE PROVIDER NPI/Tax ID*:
Phone:
Provider Name*: City, State, ZIP:
ICD-10:
Address:
Fax*:
DIAGNOSIS CODES*
ICD-10:
ICD:10
REQUESTED HOSPICE SERVICES*
Requested Start Date Requested End Date
Phone: ICD:10
Routine Home Care T2042
General Inpatient T2045 Inpatient Respite T2044
# of Hours Requested:
Continuous Home CareT2043
Other: Description:
Authorizations will be given for medically necessary services only: it is not a guarantee of payment. Payment is subject to verification of member eligibility and to the limitations and exclusions of the member's contract. Emergencies do not require prior authorization (An emergency is a medical condition manifesting itself by acute symptoms of sufficient severity which could result, without immediate medical attention, in serious jeopardy to the health of an individual). *Urgent Care is defined as medically necessary treatment for an injury, illness, or other type of condition (usually not life threatening)
which should be treated within 24 hours.
PRO_46403E Internal/State Approved 06082020 ?WellCare 2019
NA9PROFRM46403E_CAID
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