Modify or extend a preauthorization

Prior Authorization Modification and Date Extension Request

Required fields are noted with an asterisk *.

Member Information
* Member ID
* Member Name		* Date of Birth
Authorization Information
* Current Authorization Number		* Current end date
Extensions
* Has this authorization been extended before?
We will not be able to provide the date extension. Please submit a new request.
We will extend an authorization up to an additional two (2) weeks from your current end date.
Date extension reason (choose one)
What end date are you requesting?

Modifications
Are there diagnosis edits?
Diagnosis edits		What is the dx code
Providers edit?
Provider type?
Provider name	Provider phone	Provider fax
Provider address
Provider city	Provider state	Provider zip code
Requesting to end an authorization?
Requested date

Contact Information
* Contact name		* Contact number

Additional Information
Additional information
If you are a Capital BlueCross participating provider, no return phone call will be made. Please check ProAuth within one business day to validate requested modification. Out of area providers will receive a call back with in one business day of this request. The authorization is based on the member's benefits and eligibility as of today. Final determination of payment is based on the member's benefits, appropriateness of the service provided, and eligibility at the time the service is rendered and the claim is received.
Any questions, contact the Capital BlueCross Preauthorization department at 800.471.2242. UM Department Capital BlueCross PO Box 773731 Harrisburg, PA 17177-3731

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