Authorization Submission Entry
Company ID:
Master Record
Requested Date:
Drop Down Calendar
Time: Auth Action:
Drop Down Calendar
Priority Status: Auth Expiration:
Drop Down Calendar
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:
Requested Units:
Request Category: Certification Type:
Service Type: Auth Service Pkg:
Admit Type: Admit Source:
Patient Status: Facility Type Code:
Diagnosis
Diagnosis Code: (Only 12 diagnosis codes allowed)
Auth Action:
Drop Down Calendar
Auth Expiration:
Drop Down Calendar
Service Requested
Procedure Code:
Service Type:
Auth Procedure Group:
Modifier 1:
Modifier 2:
Modifier 3:
Modifier 4:
Service Line Amount:
Line Rate:
Auth Qty:
Diag Ref:
Admit Date:
Drop Down Calendar
Discharge Date:
Drop Down Calendar
Number of Days: Admit Type:
Admit Source: Requested Qty:
Request Category: Certification Type:
Service Type: Facility Type Code:
  Additional Dtl Info Auth Action Auth Expiration Auth Proc Grp Service Type Description Mod1 Mod2 Mod3 Mod4 Auth Qty Diag Ref Admit Date Discharge Date Admit Type Admit Source Req Qty Req Catg Cert Type Service Type Fac Type Code Service Line Amount Line Rate
Auth Notes
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