Approved:

1. Patient's name:
2. CPT:
3. ICD-10:
4. Ordering MD:
5. Facility:
6. Authorization#:
7. Valid Dates:
8. # of units/visits/days:
9. Orientation:
10. CRN:
--------------------------
Pending Initiation:
1.Verify Why case is pending:
2. Is there an option to get transferred to NR?
- if still pending
3. Additional information besides clinicals?
- if yes, What specific information:
- Method of delivery: Fax or Phone?:
- Specific Authorization Form?:

4. - TAT(Calendar/Business):
5. - Case number:
6. - Call reference number:
*****Verify all Details***
Thank you for your assistance. Have a great day.
--------------------------

Pending Follow-up
---1. Verify Why case is pending:
---2. Receive clinical information:
(Ask only if there was a document sent)
--- - Date:
--- - # of pages:
---3. Additional information needed?
(Yes. Get transferred to NR)
- if still pending after NR:
3.1. What specific info needed?
3.2. Method of delivery(call/fax)
3.3. Fax/Phone number?
3.4. Specific Authorization form?

---4. TAT(Days: Calendar/Business)

(Hours: Business/Regular)
5.Case number:
---6. CRN:

Thank you
---------------------------