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  • Prohealth Prior Authorization Request Form - Community Health ...

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PRIOR AUTHORIZATION REQUEST Prior Authorization Dpt. Phone 317 621-7575 or 1 800 344-8672 Fax 317 621-7984Benefits and Eligibility Phone 317 621-7565 Provider Relations Phone 317 621-7581 Patient Name DOB ID Insurance Plan PCP Name PCP Phone PCP Fax Diagnosis ICD 9 Code s Procedure CPT-4 Code s Vendor/Facility Requested Service Date of requested service Days/ Visits Requested Referred by Phone Fax Person submitting request Phone Fax SPECIALTY RE.

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The prior authorization process is seeking “approval from a health plan that may be required before you get a service or fill a prescription for the service or prescription to be covered by your plan”.

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification.

A prior authorization (PA), sometimes referred to as a “pre-authorization,” is a requirement from your health insurance company that your doctor obtain approval from your plan before it will cover the costs of a specific medicine, medical device or procedure.

Under prior authorization, the provider or supplier submits the prior authorization request and receives the decision before services are rendered.

Taking into consideration the complexity of a prior authorization request, the prior authorization process selected by a healthcare provider, requirements set out in individual health plans, and any subsequent appeals process, a prior authorization (PA) can take anywhere from same day to over a month to process.

A prior authorization (PA), sometimes referred to as a “pre-authorization,” is a requirement from your health insurance company that your doctor obtain approval from your plan before it will cover the costs of a specific medicine, medical device or procedure.

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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
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
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