Hiive Health

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PA-2025-001

Archive Case

Archive Case

Case Progress

Patient Information

Provider Information

Device/Service Details

Clinical Information

Policy Review

Quality Assurance

Letter of Medical Necessity

Review & Submit

Case Progress

Patient Information

Provider Information

Device/Service Details

Clinical Information

Policy Review

Quality Assurance

Letter of Medical Necessity

Review & Submit

Clinical Information

Step 4 of 8

Provide comprehensive clinical information to support the prior authorization request.

Basic Information

Condition Duration (Months) *

Functional Domains Affected

Mobility

Respiratory

Sleep

Vitals Summary (0-300 characters)

0 / 300

ADL Impact (0-500 characters)

0 / 500

Safety Risks Without Device (0-500 characters)

0 / 500

Conservative Therapies

Add Therapy

Add Therapy

Therapy #1

Therapy Name *

Condition Duration (Months) *

Start date *

End date *

Treatment Outcome (0-300 characters)

0 / 300

Functional Assessment Scores

Add Score

Add Score

Assessment #1

Instrument

Score (0 - 100)

Date

Imaging & Laboratory Results

Add Result

Add Result

Result #1

Type (1-60 characters)

0 / 60

Date

Result Summary (0-300 characters)

0 / 300

Upload Images

Click or drag to upload. Max 25 MB

Outcomes & Goals

Expected Outcomes (0-500 characters)

0 / 500

Alternatives Rationale (0-600 characters)

0 / 600

Adherence Plan (0-300 characters)

0 / 300

Training Plan (0-300 characters)

0 / 300

Maintenance Plan (0-300 characters)

0 / 300

Monitoring Plan (0-300 characters)

0 / 300

Remote monitoring capabilities required

Continue to policy review

Continue to policy review