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Referral Submission
Referral Submission Entry
Company ID:
Master Record
Requested Date:
Time:
Auth Action:
Priority Status:
Auth Expiration:
LOS:
Authorized Units:
Member ID:
Healthplan Name:
Name:
Gender:
DOB:
Service Area:
Authorizing Provider ID:
Service Area:
Requested Provider ID:
Service Area:
Facility ID:
Place Of Service:
From Favorites
Requested Units:
Request Category:
Certification Type:
Service Type:
Auth Service Pkg:
Admit Type:
Admit Source:
Patient Status:
Facility Type Code:
Additional
M
aster Info
Diagnosis
Diagnosis Code:
A
dd Diag
(Only 12 diagnosis codes allowed)
Auth Action:
Auth Expiration:
Service Requested
Procedure Code:
Service Type:
Modifier 1:
From Favorites
Auth Qty:
Diag Ref:
Modifier 2:
Modifier 3:
Modifier 4:
Service Line Amount:
Line Rate:
Admit Date:
Discharge Date:
Number of Days:
Admit Type:
Admit Source:
Requested Qty:
Request Category:
Certification Type:
Service Type:
Facility Type Code:
Add
P
roc
Referral Notes
(Click to Enlarge Notes)
S
ubmit Request
C
lear Form
May 2024
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