3601 SW 160th Ave Suite 450Miramar, FL 33027Fax: 866-613-0157 Email: outpatientutilization@eonhp.com

PRE-CERTIFICATION / ADMISSION NOTIFICATION FORM

Patient Information (*Required Field)*PATIENT NAME

*DATE OF BIRTH

*MEMBER ID

*ADDRESS

*CITY

*STATE

*ZIP CODE

*PHONE #

*PRIMARY CARE PROVIDER (PCP) NAME

PCP NPI

PCP PHONE #

*HOSPITAL RECORD NUMBER

CAREGIVER NAME

CAREGIVER PHONE #

Please attach all clinicals information pertinent to this request and support medical necessity.Provider Information (*Required Field)

* HOSPITAL / FACILITY NAME

*LOCATION

*HOSPITAL/FACILITY NPI

*DATE OF ADMISSION

ESTIMATED LENGTH OF STAY

*ADMITTING PHYSICIAN NAME

*ADMITTING PHYSICIAN NPI

NAME OF PERSON COMPLETING THIS FORM

DATE

*PHONE #

*FAX #

Service Type (select one)SURGICAL ADMISSION (INPATIENT) ☐ MEDICAL ADMISSION: (URGENT) ☐

OBSERVATION SERVICES ☐ MEDICAL ADMISSION: (EMERGENT) ☐TRANSPLANT ☐ MEDICAL ADMISSION: (ELECTIVE) ☐

OTHER ☐

Principal Diagnosis Principal Procedure ICD-10 CODE CPT CODE

DESCRIPTION

DESCRIPTION

Clinical indications for admission or inpatient procedure (signs, symptoms, and test results) and rationale if out of network

Attestation for Non-Participating Providers (*Required Field)

3601 SW 160th Ave Suite 450Miramar, FL 33027Fax: 866-613-0157 Email: outpatientutilization@eonhp.com

PRE-CERTIFICATION / ADMISSION NOTIFICATION FORM

THIS AUTHORIZATION SERVES AS A ONE TIME OUT OF NETWORK AGREEMENT AT THE RATE OF 100% MEDICARE ALLOWABLE FOR NON- PARTICIPATING PROVIDER. THIS AUTHORIZATION REQUEST WILL BE VALID FOR 30 DAYS.

*PROVIDER SIGNATURE:________________________________________________________ *DATE:______________________________

Instructions for Submitting a Request

Please read all instructions before completing this form:

Inpatient Notification

Eon Health requ i res notification t o the P lan o f a l l urgent/emergent inpatient admission for ALL members within 24 hours (1 day) or for admissions occurring during a weekend or holiday, by the end of the first working day, thereafter.

If the member is unable to provide coverage information, you must contact us as soon as you become aware of their coverage.

Prior authorization for urgent/emergent inpatient admission is not required.

Concurrent review includes collecting information from the care team about the member’s condition and progress and it is used by the Plan to determine if medical necessity criteria is met. Inpatient clinical records must be submitted to the plan every 3 days. Inability to satisfy medical necessity will result in denial or delay in payment of claims;

The plan requires notification upon member’s discharge.

Inpatient Certification

The Plan requires that all elective admissions and elective surgical procedures require prior authorization and a prospective review in order to ensure medical necessity and approve claims payments;

Request must be submitted to the Plan prior to admission and/or procedure;

The Plan will render a medical necessity determination based on the request type (standard/expedited). Incomplete information may cause a delay in deciding within the designated timeframe;

Prior authorizations are required regardless of reimbursement type. If the request is approved, the approval is valid for 90-day period from the date of the approval notice. If the surgery or procedure is not performed during the 90-day timeframe or the planned procedure code changes, the provider must submit a new request for prior authorization;

3601 SW 160th Ave Suite 450Miramar, FL 33027Fax: 866-613-0157 Email: outpatientutilization@eonhp.com

PRE-CERTIFICATION / ADMISSION NOTIFICATION FORM