Get The Selecthealth Request For Preauthorization Form - Intermountain ... - Intermountainphysician

This guide provides clear instructions on how to fill out the SelectHealth Request For Preauthorization Form online. By following these steps, users can complete the form efficiently and ensure all necessary information is provided for preauthorization.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the preauthorization form and open it for editing.
2. Begin by filling in the date at the top of the form, which indicates today’s date. Additionally, provide your contact name for any follow-up communication.
3. In the patient information section, enter the patient's name, date of birth, SelectHealth Subscriber ID number, and details about primary and secondary insurance carriers.
4. Indicate the patient’s gender by marking the appropriate box for male or female.
5. In the provider information section, input the requesting provider's name, street address, and the service provider’s details. List the place of service facility and their respective NPI numbers as well.
6. Select whether the service requested is inpatient or outpatient, and provide the appropriate phone number for the service provider.
7. Detail the procedures and/or services requested by entering the diagnosis code and CPT/HCPCS code. Provide a concise description of each procedure. If more space is required, attach an additional form.
8. Indicate if anesthesia is required and specify the type of anesthesia. Additionally, if an assistant surgeon is involved, provide their name and NPI.
9. Select the surgical approach used, such as open, laparoscopic, endoscopic, or robotic, and specify if any hardware or implants will be utilized.
10. If using InterQual criteria or submitting clinical notes, ensure that relevant documents are attached and clearly marked as needed.
11. After completing all sections of the form, review the information for accuracy. Then, save the changes, download, print, or share the form as necessary. Choose the preferred method of submission, whether by fax, email, or mail as detailed in the instructions.

Complete your SelectHealth Request For Preauthorization Form online today to ensure your medical procedures are properly preauthorized.