Kidney Dialysis Prior Authorization Request Form
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Form and instructions for requesting prior authorization for kidney dialysis services from WPS Health Insurance; intended for providers submitting requests on behalf of WPS customers.
No material clinical or coverage changes in this revision.
Medical Necessity Evaluation Elements
Required evaluation elements
Information required to evaluate medical necessity for dialysis prior authorization:
ALL of the following
- Ordering/referring provider information: provider first and last name, site/location name, site/location address, city, state, ZIP, provider specialty (e.g., Nephrologist), TIN, NPI, phone, fax, location contact person.
- Member diagnosis: include diagnosis code(s) (examples provided: N18.4, N18.5, N18.6) or other diagnosis as applicable.
- Glomerular Filtration Rate (GFR).
- Dialysis center selection: indicate whether a dialysis center has been chosen; if Yes, provide location name and address.
- Dialysis treatment details: dialysis type/treatment recommended (hemodialysis, home dialysis, peritoneal dialysis) and frequency.
- Kidney treatment history: include time of diagnosis, levels of care, and recent treatment history.
- Transplant status: indicate whether the customer is awaiting transplantation and provide comments as needed.
- Additional notes or comments relevant to the request.
- Acknowledgement that prior authorization approval is based on medical necessity and does not guarantee benefits or payment; verify benefits with WPS as needed.
Example Diagnosis Codes
| N18.4 | Stage 4, chronic kidney disease |
| N18.5 | Stage 5, chronic kidney disease |
| N18.6 | End-stage renal disease/acute renal failure |
Submission and Documentation Requirements
Submission instructions — preferred electronic submission via iExchange
For quicker response, submit electronically via iExchange (nexaligniexchange.medecision.com/IEApp/Login/providerLogin.faces) and attach supporting clinical documents. Fax is an alternative (non-preferred) — fax the completed form and supporting documents to the appropriate WPS fax number.
Required clinical and administrative fields — ordering/referring provider identifiers, diagnosis, GFR, clinical details
Include complete ordering/referring provider and clinical information with every request to avoid delays. Required fields include ordering/referring provider identifiers and site (TIN, NPI, provider name, specialty, phone, fax, site/location name and address), patient diagnosis (examples: ICD-10 N18.4, N18.5, N18.6 or other as appropriate), current Glomerular Filtration Rate (GFR), dialysis center choice (if known) with location/address, dialysis type/treatment recommended (hemodialysis, home dialysis, peritoneal dialysis), frequency, kidney treatment history (time of diagnosis, levels of care, recent treatment history), transplant waiting status, and any additional clinical notes/supporting documentation.
- Required provider identifiers: TIN, NPI, provider name, specialty, phone, fax, site/location address
- Diagnosis examples: ICD-10 N18.4, N18.5, N18.6 (or other documented diagnosis)
- Key clinical data: GFR, dialysis type, frequency, dialysis center name/address (if chosen), kidney treatment history, transplant waiting status
Authorization limitation / verification — approval subject to medical necessity and benefit verification with WPS; does not guarantee payment
Authorization is subject to verification of medical necessity and member benefits and does not guarantee payment. Approval is based on the terms, conditions, and exclusions of the member's benefit plan or certificate; policy exclusions, pre-existing condition language, or signed affidavits may affect coverage. Always verify benefits and authorization requirements with WPS prior to delivering services — for benefit inquiries call WPS at 800-333-5003.
- Prior authorization does not guarantee payment
- Approval is contingent on medical necessity and benefit verification
- Verify member benefits and prior authorization requirements with WPS (800-333-5003)
Selection & Transplant Status Fields
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