Get Avesis Prior Authorization Form

Filling out the Avesis Prior Authorization Form online is a crucial step for obtaining necessary vision services. This guide will provide you with detailed instructions on completing each section of the form to ensure your request is processed efficiently.

Follow the steps to complete the Avesis Prior Authorization Form online.

1. Click ‘Get Form’ button to obtain the form and open it for online completion.
2. Begin by entering the Avesis tracking number in the corresponding field. Ensure that this number is accurate, as it will help in tracking your authorization request.
3. Fill in the expiration date of the prior authorization request. This ensures that your request remains valid for the required period.
4. Provide the member's full name in the designated field. This should match the name on the insurance policy.
5. Indicate the type of vision services requested by selecting either 'Contact lenses' or 'Other' in the request for services.
6. Add the member's date of birth to verify their identity and ensure proper processing of the request.
7. Enter the member's ID number, which is typically found on their insurance card, to assist in identifying their insurance coverage.
8. Complete the address section with the member's current residence details, including city, state, and zip code.
9. Next, provide the requesting provider's name and Avesis provider number. This identifies who is making the request.
10. Fill out the requesting provider's address, ensuring to include city, state, and zip code for accurate communication.
11. Provide contact information for the contact person responsible for the request, including their office phone and fax numbers.
12. Select the CMO and enter the relevant state information to ensure proper jurisdiction.
13. Fill out the e-mail field for digital correspondence regarding the authorization request.
14. Detail the services requested, including the description, CPT codes, ICD-9 codes, and patient prescriptions for the right and left eye.
15. Include any additional notes that may be pertinent to your request, along with a reminder to attach any necessary office notes and diagnostic test results.
16. Once the form is complete, review for accuracy, save your changes, and then you can proceed to download, print, or share the completed form.

Complete the Avesis Prior Authorization Form online today to ensure your authorization request is processed efficiently.