Get Request For Preservice Review - Anthem

Filling out the Request For Preservice Review form for Anthem is an essential step in ensuring that necessary medical services are authorized. This guide provides clear instructions to help users navigate the form easily and accurately.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the Request For Preservice Review form and open it in your preferred editor.
2. Begin filling out the date request submitted field accurately by entering the current date.
3. Enter the member's name in the designated space, ensuring all spelling is correct.
4. Provide the member's date of birth and age in the respective fields.
5. Input the certificate number associated with the member.
6. Indicate the member's sex by selecting either the male or female option.
7. Fill in the address, including street, city, state, and ZIP code of the member.
8. Enter the member's contact phone number.
9. Complete the requesting physician's name and license number.
10. Input the tax identification and National Provider Identifier (NPI) numbers for the physician.
11. Fill in the requesting physician's address, ensuring to include all the necessary details.
12. Provide the contact phone number for the requesting physician.
13. Identify who is completing the form by entering their name and contact details.
14. Circle the option that pertains to the request: medical or surgical.
15. If known, specify the date of service.
16. Indicate whether the service is inpatient or outpatient by circling the appropriate option.
17. Provide the diagnosis information and include the relevant ICD-9 code.
18. Fill in the procedure being requested along with the corresponding CPT/HCPCS code.
19. Enter the facility name associated with the service provider.
20. Complete the service provider's tax ID or Medicare ID number as applicable.
21. Include the service provider's full address and contact information.
22. Indicate if the service provider is in-network or out-of-network by selecting the correct option.
23. Provide a detailed history or treatment that has been provided by the referring physician.
24. Make sure to include any necessary clinical information to justify the request, as outlined in the guidance provided.
25. Once all fields are completed, users can save changes to the form, download it, print it, or share it as needed.

Complete your Request For Preservice Review form online for a smoother approval process.