Get Anthem Bcbs Of Ohio Prior Authorization Form

Filling out the Anthem Bcbs Of Ohio Prior Authorization Form online is an essential process for obtaining necessary approvals for medical treatments. This guide will provide clear, step-by-step instructions to assist users in completing the form accurately and efficiently.

Follow the steps to complete the online form efficiently.

1. Press the ‘Get Form’ button to access the Anthem Bcbs Of Ohio Prior Authorization Form and open it for editing.
2. Begin by entering the date of the request at the top of the form.
3. In the recipient information section, input the last name, first name, middle initial, date of birth, recipient ID, gender, and phone number.
4. Next, provide the prescribing provider's information, including their name, NPI number, phone number, and required fax number. Specify the person to contact regarding the request.
5. In the diagnosis and requested drug section, you must include the applicable ICD-9 code along with the related diagnosis or symptoms. Fill in the name, strength, dosage, and duration of the requested drug, ensuring that the generic substitution is not permitted.
6. For clinical information, explain any known allergies or unacceptable side effects that the recipient has experienced with preferred medications. List the preferred medications that were tried and failed for the diagnosis, including their name, reason for failure, and dates.
7. Outline any contraindications or potential drug-drug interactions with the preferred medications. Include any additional clinical information if needed.
8. Check the applicable boxes to confirm if the non-preferred drug is being requested for a unique indication supported by peer-reviewed literature or if the member was recently discharged from a mental health facility on the requested medication, providing the discharge date.
9. Complete the provider certification section by including the prescriber’s signature and date. This certifies that the treatment is indicated and necessary.
10. Finally, review all provided information for accuracy. Once completed, save the changes, download or print the form, and share it as needed.

Start filling out the Anthem Bcbs Of Ohio Prior Authorization Form online today to ensure timely approvals for your medical needs.