Get Prior Authorization Request Form Member ... - Optumrx

The Prior Authorization Request Form Member ... - OptumRx is an essential document for obtaining necessary approvals for medication. This guide will walk you through the process of completing the form online, ensuring all required information is accurately provided to facilitate smooth processing.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the form and open it in the designated editor.
2. Fill out the member information section. Include the member's full name, insurance ID number, date of birth, and contact details such as street address, city, state, and zip code.
3. Complete the provider information section. This requires the provider's name, NPI number, office phone, and office fax number.
4. In the medication information section, input the medication name, its strength, and confirm if this is a new medication start. Provide directions for use and the dosage form.
5. For clinical information, select the appropriate diagnosis from the list provided. If applicable, state any other diagnosis and include the corresponding ICD-9/10 codes.
6. Indicate any previous medications the patient has tried, including any intolerances or contraindications.
7. Complete the quantity limit requests by specifying the requested amount per day.
8. Answer the specific questions about the patient's diagnosis and whether the medication was prescribed by a pain specialist.
9. Check all documentation that has been maintained and documented in the chart notes, ensuring you meet the required criteria.
10. Indicate whether chart documentation will be submitted alongside this form. Provide any additional comments or necessary information that may support the authorization request.
11. Once all sections are filled out, you can save your changes, download the form, print it, or share it as needed.

Complete your Prior Authorization Request Form online today to ensure timely processing!