PRE-CERTIFICATION REQUEST FORM FOR SERVICES OUTSIDE OF GUAM

PRE-CERTIFICATION REQUEST FORM FOR SERVICES OUTSIDE OF GUAM
Pre-Certification is required for all in-patient confinements, outpatient surgery, diagnostic testing, radiation therapy, sleep evaluation, hyperbaric oxygen treatments, home health care, private duty nursing, physical therapy & DME.

All Pre-Certification Form (s) must be completed by the attending physician or nurse and faxed to NetCare at least 48 hours prior to the services being rendered. We ask for your adherence and compliance with this policy.

Failure to obtain pre-certification approval for those services or benefits requiring prior authorization from NetCare may result in a disallowance of up to 50% of charges.

Please note that pre-certification is only a determination of medical necessity, not an assurance of coverage, or guarantee of payment.
Member's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex
Date of Request*

MonthDayYear
Date
Member's NetCare ID No.*
Subscriber's Name*

First NameLast Name
Social Security No.
Benefit Plan
Effective Date

MonthDayYear
Date
Member's Mailing Address
Relationship to Subscriber
On Island Contact #
Off Island Contact #
Name of Requesting Provider/PCP
Provider Tax ID #
Office Tel #
Office Fax #
TYPE OF PROCEDURE REQUESTED, LIST CPT CODES (REQUIRED FOR REVIEW):
Diagnosis/ICD-9 Codes/Clinical Findings (Please attach clinical notes, laboratory and/or imaging results):
Outpatient Surgery (Indicate type of surgery):

In-Patient (Hospital, Rehab, SNF)Durable Medical EquipmentMRI/CT Scan/ Ultrasound/ Echocardiogram/ Audiological evaluation or other Diagnostic Procedures (Please Indicate)Out Patient Surgery (Indicate type of Surgery)Home Health CareOther
Outpatient Surgery (Indicate Type of Surgery)
Diagnostic Procedure (Indicate Type of Procedure)
Surgery Assistant

YESNO
Provider/ Physician/ Clinic Rendering Services
Name*
Address
Tax ID Number (required)*
Tel #
Fax #
Date of Service

MonthDayYear
Date
AXA NetworkCOCPARNON-PAR
Facility where service is to be performed:
Name*
Address
TAX ID Number (required)*
Tel #
Fax #
Date of Service

MonthDayYear
Date
AXA NetworkCOCPARNON-PAR
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PRE-CERTIFICATION REQUEST FORM FOR SERVICES OUTSIDE OF GUAM

Provider/ Physician/ Clinic Rendering Services

Facility where service is to be performed: