Preauthorization for inpatient elective admission
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This document is a Capital Blue Cross preauthorization form and instructions for requesting prior authorization for non-emergent (elective) inpatient admissions; it affects providers submitting authorization requests for members covered by Capital Blue Cross products in North Carolina and other listed products. It describes required member, clinical, and provider information and submission instructions.
No material clinical or coverage changes in this revision.
Authorization Form Requirements
Authorization form criteria
Information required to support authorization review
ALL of the following
ALL of the following
- Member name (full)
Section I: Member information
- Member ID
Section I: Member information
- Date of birth
Section I: Member information
- Product (e.g., CHIP, Commercial, FEP, Medicare Advantage)
Section I: Member information
- Other insurance (if applicable)
Section I: Member information
ALL of the following
- Place of service (e.g., Hospital or Other)
Section III: Clinical summary
- Admission date and end date (or requested admission dates)Requested admission dates/number of days must be provided on form
Section III: Clinical summary
- Requested units/days
Section III: Clinical summary
- Primary diagnosis
Section III: Clinical summary
- Additional diagnoses: Additional diagnosis(es)
Section III: Clinical summary
- Primary procedure/HCPC codes (to be provided by requesting provider)
Section III: Clinical summary
ALL of the following
- Servicing provider name and NPI
Section III and Section I as applicable
- Facility details: Facility name and NPI (if applicable)
Section III
- Provider/facility address and contact information
Section I/III
- Requesting provider information (if different from servicing provider)
Section I
ALL of the following
- Required documents: Most recent history & physical (H&P), progress notes, diagnostic studies, photos, molds (include all pertinent clinical information to prevent delay)
Section VI: Additional information
ALL of the following
- Select level of urgency: Standard or Expedited
Section II: Authorization
- Expedited justification: If Expedited is selected, provide explanation/justification that delay could seriously jeopardize life/health or cause adverse consequences per practitioner judgment
Section II: Authorization
- Physician signature and date
Section VII: Physician signature; preauthorization is not a guarantee of payment
ALL of the following
- Fax completed form and all documentation to 717.651.8966
Preauthorization submission
- Questions: contact Preauthorization department at 800.471.2242
Provider contact
- Mail letters of medical necessity to UM department, Capital Blue Cross, PO Box 773731, Harrisburg, PA 17177-3731
Submission mailing address
Section VII: Physician signature
Procedure Codes and Admission Details
| Primary procedure/HCPC codes to be provided by requesting provider |
Submission and Payment Notices
Complete and fax the preauthorization form with required clinical attachments
Complete all required fields on the preauthorization form and fax the completed form with member information, clinical summary (including place of service, admission date/end date, requested units/days, primary and additional diagnosis, primary procedure/HCPC codes) and all pertinent clinical documentation (most recent H&P, progress notes, diagnostic studies, photos, molds) to Capital Blue Cross preauthorization at fax 717.651.8966. For questions contact the Preauthorization department at 800.471.2242. Indicate level of urgency (standard or expedited) and include physician signature and date; expedited requests must include justification that delay could seriously jeopardize life or health or cause adverse consequences per practitioner judgment.
- Fax completed form to: 717.651.8966
- Include: member name/ID/DOB/product, place of service, admission dates, requested units/days, primary/additional diagnosis, primary procedure/HCPC codes
- Attach pertinent clinical documentation: most recent H&P, progress notes, diagnostic studies, photos, molds
- For questions call Preauthorization department 800.471.2242
- Select urgency level (standard or expedited) and include physician signature and date
Preauthorization is not a guarantee of payment
Obtain preauthorization using the form and signature, but note that preauthorization does not guarantee payment; coverage and payment remain subject to the terms of the member's benefit program.
- Physician signature and date required on Section VII
- The form states: “Preauthorization is not a guarantee of payment.”
Request Types
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