PROPOSED FORM - For Review
INSURANCE VERIFICATION FORM
Section 1: Demographics / Section 2: Prior Authorization
MEMBER INFORMATION
Member Name
Date of Birth
SSN (Last 4)
Address
PRIMARY INSURANCE - MASSHEALTH
MassHealth ID #
Verification Date
Verified By
Verification Method
EVS Portal
Phone (1-800-841-2900)
POSC
Coverage Type
MassHealth Standard
MassHealth CommonHealth
MassHealth CarePlus
Other: ____________
Effective Date
Termination Date (if known)
ELIGIBLE
for MassHealth AFC Services
NOT ELIGIBLE
- Reason: ___________________________
MANAGED CARE ORGANIZATION (MCO) / SCO
MCO/SCO Name
Fallon Health
Senior Whole Health
Tufts Health Plan
Commonwealth Care Alliance (CCA)
UnitedHealthcare
None (Fee-for-Service)
MCO Member ID #
MCO Phone #
Effective Date
PRIMARY CARE PROVIDER
PCP Name
NPI #
Practice Name
Phone
Fax
Address
AFC ELIGIBILITY CONFIRMATION
AFC Prior Authorization Status:
PA Not Yet Requested
PA Pending - Submitted: ____________
PA Approved - Auth #: ____________ Expires: ____________
PA Denied - Reason: ____________
Service Level Authorized
Level I
Level II
Authorization Period
VERIFICATION NOTES
Completed By
Date
Supervisor Review