Get Peach State Health Plan Prior Authorization

This guide provides clear and detailed steps for completing the Peach State Health Plan Prior Authorization form online. By following these instructions, users can efficiently submit their requests for prior authorization and ensure they have included all necessary information.

Follow the steps to complete the online form accurately and efficiently.

1. Press the ‘Get Form’ button to access the Peach State Health Plan Prior Authorization form and open it in your preferred online editing tool.
2. Begin with patient information. Fill in the patient's name, address, city, state, zip code, home phone, alternate phone, date of birth, and gender in the designated fields.
3. If applicable, provide information for other shipping locations. Include the name, address, city, state, zip code, phone, fax, and contact name.
4. Complete the prescriber information section. Enter the prescriber's name, specialty, NPI number, group or hospital, address, city, state, zip, phone, fax, contact name, and if the medication will be supplied from different location.
5. Fill out the insurance information for both primary and secondary insurance plans, including insurance names, ID numbers, and phone numbers.
6. In the statement of medical necessity section, specify the diagnosis with the associated ICD9 code and description. Include the date of diagnosis and any necessary clinical documents.
7. Indicate whether the member is currently being treated with the requested medication(s) and provide the duration of treatment. Also specify if this is a continuation of a previous approval and any changes in strength, dosage, or quantity.
8. Enter the medication(s) requested, including the medication name, strength/dose, directions, quantity, and refills required.
9. Ensure the prescriber signs and dates the form before submission.
10. After thoroughly reviewing all the provided information, save the changes, download, print, or share the completed form as needed.

Start completing the Peach State Health Plan Prior Authorization form online to ensure timely processing of your request.