REQUEST FOR HEALTH PLAN INITIAL DETERMINATION. CLINICAL ... FAX #: 866-461-2401 Attention: Investigational/Clinical Trial Nurse. For Questions Call: .
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How to fill out the Request For Health Plan Initial Determination Clinical Trial - Initial And Bb online
This guide provides clear and supportive instructions for completing the Request For Health Plan Initial Determination Clinical Trial - Initial And Bb form online. Whether you are submitting a request or seeking an expedited review, this guide will help you navigate the required sections with ease.
Follow the steps to complete your request efficiently.
- Click the ‘Get Form’ button to access the form in your browser.
- Begin by indicating the type of request, selecting either 'Cancer' or 'Non-Cancer,' and specify whether it is an 'Initial Trial' or 'Extension.'
- Provide the requesting provider's name, facility or institute name, and contact details including phone and fax numbers.
- Enter the names and contact information for the trial coordinator and research coordinator, ensuring all information is accurate.
- Input the relevant ICD9 codes and requested CPT codes related to the investigational treatment.
- List the services for which you are requesting investigational review, and enter the principal investigator's details.
- Specify whether you are requesting an expedited review by selecting 'YES' or 'NO' and provide necessary UR contact information.
- Attach any required medical records, ensuring they include the record of initial assessment and relevant progress notes.
- Finally, review all the filled information for accuracy, save your changes, and then download, print, or share the completed form as needed.
Complete your request online today for a streamlined experience.
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