Follow the steps to complete the HMSA PRECERTIFICATION Request Form online.

1. Press the ‘Get Form’ button to access the HMSA PRECERTIFICATION Request Form and open it in the designated editor.
2. Begin by providing the provider contact information, including the contact name, phone number, and fax number for any inquiries related to the request.
3. Next, fill out the member information section. This includes entering the membership number, patient’s name (last, first, middle initial), date of birth, subscriber’s name, and their phone number.
4. In the ICD-9-CM diagnosis code(s) section, input the relevant code(s) that corresponds to the patient's condition.
5. Proceed to the procedure/service/treatment information section. Include the CPT/HCPCS code(s) and specify the place of service, selecting from options such as inpatient, outpatient, office, or ambulatory surgical center.
6. Complete the provider information. Enter the requesting or referring provider's name, provider ID, and their contact information, including address, phone number, and fax number. If there is a servicing provider different from the requesting provider, fill in those details as well.
7. If applicable, complete the section for the servicing facility/vendor name and provide their provider ID, address, phone number, and fax number.
8. In the reason for referral to an in-state nonparticipating or out-of-state provider section, include the rationale for the referral. Remember to attach any supporting documentation to prevent delays in processing.
9. Once all sections are filled out, review the form for accuracy. Users can then save changes, download, print, or share the form using the options available in the editor.

Complete your HMSA PRECERTIFICATION Request Form online now for a smooth submission process.