VIVA HEALTH Form: Inpatient and Outpatient Precertification

Submit the completed VIVA HEALTH Precertification Form via fax to (205) 449-7049. For any questions or additional assistance, contact VIVA HEALTH's Medical Management Department at (205) 933-1201. Ensure all required fields are filled out accurately and attach any necessary supporting documentation before sending. My advice is to double-check all entries and attached documents to avoid any processing delays.

Please check with VIVA HEALTH for any updates or changes to this form's requirements and submission deadlines.

The primary purpose of the VIVA HEALTH Inpatient and Outpatient Precertification Form is to streamline the approval process for healthcare services. By providing detailed patient information, diagnosis, and treatment plans, this form ensures that the requested services align with the member's benefit plan. Completing this form accurately helps facilitate timely approvals, appropriate billing, and effective care coordination.

• 1. Patient Name: Full name of the patient receiving the services.
• 2. Member Number: Patient's insurance member number for identification.
• 3. Person Completing Form: Name of the person filling out the form.
• 4. Admitting MD: Name of the admitting physician responsible for the patient's care.
• 5. MD NPI: National Provider Identifier of the admitting physician.
• 6. Diagnosis: Patient's medical diagnosis related to the requested services.
• 7. ICD-10 Code: International Classification of Diseases code for the diagnosis.
• 8. Admit Date or Procedure Date: Date of patient admission or the date of the procedure.
• 9. Prior Level of Function: Patient's functional level prior to the current diagnosis or condition.
• 10. Current Level of Function: Patient's current functional level at the time of submitting the form.
• 11. Past Medical History: Summary of the patient's relevant past medical history.
• 12. Date of Birth: Patient's date of birth.
• 13. Group Number: Insurance group number associated with the patient's policy.
• 14. Phone: Contact phone number for the patient or the person completing the form.
• 15. Facility Name: Name of the facility where services will be provided.
• 16. Facility Tax ID: Tax identification number of the facility.
• 17. Procedures: Details of the medical procedures being requested.
• 18. Requested Length of Stay: Number of days requested for the patient's stay.
• 19. Summary of Previous Outpatient Treatment: Attach clinical information and a summary of past outpatient treatments.
• 20. Medical Indication for Requested Service: Medical justification for the requested healthcare service.
• 21. Treatment Plan: Outline of the planned treatment for the patient.
• 22. FOR DELIVERY ADMIT EDC: Estimated date of confinement for delivery if applicable.
• 23. Expected Type of Delivery: Anticipated method of delivery, such as vaginal or cesarean.
• 24. VIVA HEALTH USE ONLY: Section to be completed by VIVA HEALTH for internal processing.
• 25. Medicare, Commercial, VIVA MEDICARE Me, Other Insurance: Insurance information of the patient.
• 26. Fax: Fax number for sending the completed form.
• 27. CPT: Current Procedural Terminology code related to the requested services.

Failure to submit this form may result in delays or denial of service coverage. It is essential to ensure all information is accurate and submitted in a timely manner.

• Delayed Approvals: Without this form, approval for requested services may be delayed, impacting patient care.
• Service Denial: Incomplete or missing forms may lead to the denial of coverage for medical services.
• Billing Issues: Inaccurate or incomplete forms can cause discrepancies in billing and potential financial liabilities.

• 1. Inpatient Services: Use this form to request precertification for inpatient medical services.
• 2. Outpatient Services: Use this form for precertification of outpatient medical treatments.
• 3. Surgical Procedures: Submit this form to obtain approval for scheduled surgical procedures.
• 4. Special Treatments: When requesting special treatments or therapies, this form is required.
• 5. Extended Hospital Stay: Use this form to request an extension of the patient's hospital stay.