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Get Or Careoregon Inpatient - Prior Authorization Form 2019-2026
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How to use or fill out the OR CareOregon Inpatient - Prior Authorization Form online
Filling out the OR CareOregon Inpatient - Prior Authorization Form is an essential step for obtaining necessary services. This guide provides clear, step-by-step instructions to assist users in completing the form accurately online, ensuring a smooth authorization process.
Follow the steps to fill out the form correctly.
- Press the ‘Get Form’ button to obtain the authorization form and open it for editing.
- Begin with the 'Person completing the form' section. Enter your name, indicate whether you are working at a primary care provider (PCP) office or a specialist office, and fill in the date, phone number, and fax number.
- In the 'Member name' section, enter the last name, first name, middle initial, date of birth, and subscriber ID of the member for whom you are requesting authorization.
- Fill out the 'PCP name' and 'Clinic name' fields to identify the primary care provider.
- In the 'Provider names' section, input the specialist's name, their fax number, the clinic name, the facility name, and the tax identification number (Tax ID) of the facility.
- For the 'Diagnosis (Dx) / Procedure Information', provide the primary diagnosis and its corresponding code, the primary procedure with its CPT/CDT-4 code, and any secondary diagnoses or procedures if applicable.
- Respond to the question regarding comorbid conditions. Mark 'Yes' or 'No', and if 'Yes' is selected, describe the condition(s) and provide the diagnosis code along with a narrative explanation.
- Complete the 'Level of care requested' section by indicating whether the request is for a hospital inpatient stay, the anticipated admit date, and the expected number of days.
- Make sure to attach relevant chart notes with your authorization request as mentioned in the instructions.
- After ensuring all fields are correctly filled out, you can save the changes, download the form for your records, print a copy, or share it as needed.
Start completing your OR CareOregon Inpatient - Prior Authorization Form online today!