Get Hmaa Precertification Request Form 2020-2025

Completing the Hmaa Precertification Request Form is a crucial step in ensuring that your recommended medical services are reviewed for medical necessity. This guide will provide clear, step-by-step instructions on how to accurately fill out the form online.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the Precertification Request Form and open it in your preferred editor.
2. Enter the date of the request in the designated field at the top of the form.
3. Fill out the 'FROM' section with your name and contact information.
4. Provide the contact person’s name, phone number, and fax number if it is different from the requesting physician.
5. In the ‘Requesting Physician’ section, include the name, phone number, and fax number of the physician requesting the precertification.
6. Complete the 'Name of Patient' field with the patient’s full name.
7. Select the patient's sex by marking either ‘Male’ or ‘Female’.
8. Fill in the ‘Name of Subscriber’ with the name of the individual who holds the health plan.
9. Enter the patient’s date of birth in the format mm/dd/yy.
10. Provide the Member ID Number associated with the health plan.
11. List the diagnosis using ICD-9 codes and provide a description of the diagnosis.
12. In the ‘Requested Services’ section, input the appropriate CPT/HCPCS/NDC codes and their descriptions.
13. Indicate the anticipated date(s) of service and the anticipated date of surgery, if applicable.
14. Include the name of the facility that will provide the requested services.
15. Provide pertinent clinical information and medical justification for the requested services in the provided space.
16. Attach relevant supporting documentation, such as history and physical notes, diagnostic reports, and progress notes.
17. For outpatient rehab services and home health facilities, fax a signed copy of the treatment plan with this request.
18. Sign the form in the ‘Authorized By’ section to finalize the request.
19. Once all sections are completed, you can save the form, download a copy, print it, or share it as needed.

Complete your Hmaa Precertification Request Form online today for a smooth and efficient medical review process.