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Necessity for the requested service. If this is a DME request, attach an itemized list of codes and costs Patient DoD ID/Benefits # or Sponsor SSN Sponsor Name Patient Name Date of Birth Address City State Telephone ( ) Zip Code Patient s Relationship to Sponsor Requesting Provider Contact Name TIN NPI (NPI Optional) Address City State Telephone ( ) ICD-9 Zip Code Fax ( ) Diagnosis (Select One) Inpatient Outpatient Facility Home Office Ambulatory Infusion Suite (AIS) (.

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Phone requests: Call 1-800-555-CLIN (2546), Monday – Friday, 8 a.m. – 8 p.m., local time. Fax requests: Complete the applicable form and fax it to 1-877-486-2621.

Submitting the Prior Authorization Request For prior authorization requests initiated by phone, the prescribing provider must submit the required supporting clinical documentation of medical necessity by fax to 717-265-8289.

Submit your own prior authorization request. Download, fill out and fax one of the following forms to 877-486-2621: Request for Medicare Prescription Drug Coverage Determination – English.

Uploading records online allows for faster adjudication of claims. Log in to Availity Essentials at Availity.com, opens new window. ... From the “Payer Spaces” menu, select “Humana.” From the “Applications” tab, select “Medical Records Management,” locate the record request, and upload the records.

Prescribers with questions about the prior authorization process for professionally administered drugs should call 1-866-488-5995 for Medicare requests and 1-800-314-3121 for commercial requests.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232