Authorization Request / Prior Authorization Submission
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This document governs submission of prior authorization requests to CommunityCare’s Medical Management, including required clinical information and contact/fax details; it affects ordering providers and servicing facilities seeking authorization for patient services.
No material clinical or coverage changes in this revision.
Authorization validity and payment
Authorization validity and payment
Administrative stance regarding authorization and payment:
ALL of the following
- Authorization indicates CommunityCare has determined the requested services are medically necessary and appropriate but does not guarantee payment.
- The member must be eligible on the date the service is rendered for the authorization to be valid.
- CommunityCare does not guarantee eligibility for patients covered by a group health plan or any Medicare plan; it relies on eligibility information provided by the employer or CMS.
- Payment is subject to benefit plan limits; the patient is financially responsible for costs if determined ineligible or if benefit limits are exceeded.
Documentation and submission note
- Clinical information such as previous diagnostic testing and medications should accompany the request to determine medical necessity.
- Failure to submit pertinent supporting documentation can result in the request being denied.
- Fax the completed authorization request form with all pertinent clinical information to Medical Management at 918-878-5900 or 1-800-594-0105.
Requested Codes
| CPT | Place CPT code(s) on form as applicable |
| NDC | Place NDC number(s) when relevant |
Submission, Required Fields, and Denial Risk
Authorization Request Submission
Complete and fax the authorization request form with all pertinent clinical information to Medical Management at 918-878-5900 or 1-800-594-0105 (toll-free). Include a contact name, date, phone number, and fax number; by submitting you certify the phone and fax numbers are accurate, secure, and confidential.
- Fax: 918-878-5900 or 1-800-594-0105 (toll-free)
- Questions: Pharmacy Services 918-594-5211 or 877-293-8628
Required Form Fields
Indicate the required form fields on the authorization request: patient identifiers, ordering physician and contact details, type of service/service category, priority, dates of service, quantity, servicing provider/facility, diagnosis code(s) and description(s), CPT code(s)/procedure(s), NDC # (if applicable), and any relevant clinical information (previous diagnostic testing, medications, remarks).
- Patient Name, ID Number, DOB, Patient Phone Number
- Ordering Physician name, Phone Number, Fax Number
- Type of Service / Service Category (e.g., Office Visit, Diagnostic Testing, Outpatient Procedure, Inpatient, DME, SNF, LTAC, ER/Urgent Care, Other)
- Priority (Urgent, Routine, Retro, To be determined)
- Quantity and Dates of Service(s)
- Servicing Provider/Facility
- Diagnosis Code(s) and Diagnosis(es)
- CPT Code(s) / Procedure(s); NDC # when applicable
- Remarks / Additional Information and supporting clinical documentation
Denial Risk for Incomplete Documentation
Failure to submit pertinent supporting documentation or to fully complete the authorization form can result in denial of the request. Authorization is not a payment guarantee — member eligibility and plan limits apply on the date of service.
- Incomplete forms or missing clinical documentation = denial risk
- Authorization ≠ payment guarantee; member must be eligible on date of service
- Payment subject to benefit plan limits and employer/CMS-provided eligibility
Key Definitions
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