Pre-authorization Service - Sample Communication Spreadsheet
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ABCDEFGHIJKLMNOPQRSTUVWXYZAAABACADAEAF
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Date and Time Requested First NameMiddle NameLast NameDate of BirthPatient AddressRendering Provider NameReferring Provider NamePayer NameDate of ServicePlace of ServicePrevious Authorizations # if anyDiagnosis CodeCPT Codes (Up to 4 CPT Codes)No visits required & DurationDocuments Needed for Pre-authorization (if any)Date and Time Completed Current Status
Pre-Authorization Number
Auth Effective Date
Auth End Date
Number of Visits Approved
Number of Visits Already Used
Approved CPT Codes
Documents uploaded through Web Portal
Date of callInsurance Company Rep Reference #
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JoeKAnderson1-6-78
100 Main Street
Jamie SmithAndrea CoulterAetna9-5-1811NoneR298M54.48NoneA23033009-15-1810-15-18123
97110, 97114, 97150, 97001
Yes / NoYes - 9-15-189-15-18JonathonA2309340
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It is mandatory for the clinic to provide all the elements in green. Once provided, the preauthorization center team will reach out to the payer, obtain the data points marked in yellow (within 2-6 hours in most cases), and provide the data points in yellow, by updating this spreadsheet in real time.
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If you need more data points not specifically mentioned here, please notify your sales representative, who will let you know whether or not this information can be retrieved and provided to you on a regular basis. Any requests for additional data points will incur additional costs, and is subject to approval by your sales representative. Please note that additional data points may also result in increased delivery time.
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