Get Retro Authorization

Filling out the Retro Authorization form can seem daunting, but this guide will provide you with clear instructions to ensure a smooth process. By following the steps outlined below, you can efficiently complete the form with confidence.

Follow the steps to properly complete the Retro Authorization form online.

1. Use the ‘Get Form’ button to access the Retro Authorization form and open it in your preferred editing tool.
2. Enter the member's personal information, including their name, date of birth, member number, age, and gender. Ensure this information is accurate to facilitate processing.
3. Provide details about the primary care provider (PCP) by filling in the PCP's name, contact information, and phone number.
4. Fill in the requesting provider's details, including their name, contact information, and phone number.
5. Specify the ICD-9 and CPT/HCPCS codes as applicable, and check the appropriate boxes if you are attaching any supporting documents, such as notes or imaging results.
6. Indicate the referral requested, including the name and specialty of the provider, and specify whether only an evaluation/consult is requested or if treatment is needed.
7. Detail the authorization requested for the service or procedure, including the provider or facility name, whether they are participating or non-participating, and the admission/service date.
8. For non-participating providers, ensure to include additional contact information and specify the reason for the authorization request.
9. List any diagnostic imaging required and mark whether it falls under emergent or elective categories, as well as any items requiring prior approval, especially for DME.
10. After completing all sections, review the form for accuracy, and confirm all required fields are filled out appropriately.
11. Finally, save your changes, download the form for your records, and print or share it as necessary.

Complete your Retro Authorization form online today for a streamlined process.