Date of Request:

NPI:

Tax ID:

Provider Name:

Address 1:

Address 2:

City:

State:

Postal Code:

Contact Person:

Phone Number:

Fax Number:

Subscriber/Member Number:

Date of Birth:

Last Name:

First Name:

Patient Phone Number:

Patient Height:

Patient Weight:

Ordering Physician Name:

Ordering Physician Phone Number:

Ordering Physician NPI:

Other Insurance Name:

Other Insurance Number:

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Have you uploaded the medical documentation necessary to review this request?
(i.e. requests for over-quantity should have valid prescription and LOMN attached)

 

Is this an urgent/emergent request?

 

Was this dispensed from a loan closet or stock and bill?

 

Manufacturer cost invoices must be submitted for NOC/IC codes. If this is an NOC/IC code request, have you uploaded your manufacturer cost invoice?

To document medical necessity for the item/service requested above, the written diagnosis and supporting clinical information must be attached and included with your request, and be signed by a qualified practitioner (PCP, treating Physician/ARNP).

 

With the EXCEPTION of the Authorization Exclusion List, all other durable medical equipment, prosthetics, orthotics and medical supply (DMEPOS) services require a preauthorization. If any DMEPOS service is provided without a preauthorization, the claim will be denied. THE AUTHORIZATION EXCLUSION LIST DOES NOT APPLY TO BLUE CROSS COMPLETE REQUESTS FOR AUTHORIZATION. AUTHORIZATION MUST BE OBTAINED FOR ALL DMEPOS SERVICES.

 

Authorizations are performed Monday thru Friday, 8:30 a.m. to 5:00 p.m. Urgent/emergent requests for services performed after-hours or on weekends need to be requested within the next two (2) scheduled business days. Requests for authorizations requested outside the timeframes will result in an Administrative Denial.

 

If you do not receive a response to your fax request within 2 business days please call Northwood at 1-800-393-6432.