CT Abdomen-Pediatric: Prior Authorization Request for Advanced ...

Prior Authorization Requestfor Advanced Imaging ChecksheetPuget Sound contracted providers (King, Kitsap, Lewis, Mason, Pierce, Snohomish,Thurston counties): Fax to Radiology Appointing Center: 206-988-2906All other providers: Fax to Pre-Service Department toll-free: 1-888-282-2685This form can be used by providers who cannot access Group Health’s online Referral Request toolat MyGroupHealth for Contracted Providers at ghc.org or through OneHealthPort.com.Patient Name Member #Presenting Diagnosis Code (ICD-9)Date of BirthOrdering Provider Tax ID #Clinic Contact Phone # Fax #Referred To Provider/Facility Phone #Date Procedure Scheduled (if applicable)On The Job Injury? Yes No(Circle one of the code numbers below)CT Abdomen—Pediatric: 74150, 74160, 74170, 74175 Lower abdominal pain A) Right-lower quadrant pain, suspect appendicitis A) Right-lower quadrant pain, fever, leukocytosis, careful watch appendicitis A) Right-lower quadrant pain, leukocytosis, atypical for appendicitis D) Other: Upper Abdominal pain B) Right upper quadrant pain, fever, elevated white blood cells, possible Murphy sign (ultrasound) D) Other: Abdominal pain A) Generalized abdominal pain A) Postoperative patient with fever, suspect abscess D) Other: Abdominal palpable mass A) Palpable abdominal mass D) Other: Renal Evaluation A) Pyelonephritis, persisting >72 hours, (ultrasound preferred) B) Hematuria (except parenchymal disease females with hemorrhagic cystitis); consider ultrasound C) Pyelonephritis, uncomplicated,

Crohn’s disease evaluation A) Suspect Crohn’s (initial presentation with abdominal pain, fever, or diarrhea) A) Known Crohn’s; age