Get Standardized Prior Authorization Form Instructions - Well Sense...

Completing the Standardized Prior Authorization Form Instructions - Well Sense... online is a straightforward process. This guide provides step-by-step instructions to help you effectively fill out the form, ensuring that all necessary information is included for a smooth submission.

Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date at the top of the form. This date is important for processing your request.
3. In the member information section, fill out the member's name, date of birth in MM/DD/YYYY format, member ID number, direct phone number, and fax number.
4. Next, provide your own details in the submitted by/sender information section, including your name.
5. Fill in the requesting provider information, including the provider's name, NPI number, and designate whether they are a primary care provider or specialist.
6. Indicate the servicing provider or group name along with their NPI number and address where the member will be seen, including phone and fax numbers.
7. Proceed to the requested services section. For office visits or consultations, check the reason for the visit and enter any necessary details such as the date last seen, requested start date, number of visits, and the required diagnosis and CPT codes.
8. For surgical requests, check whether the surgery is inpatient or outpatient. Provide necessary codes and the scheduled date.
9. If applicable, fill out the outpatient rehab section by entering the number of visits required for physical therapy, speech therapy, occupational therapy, and the related diagnosis and CPT codes.
10. For home health care requests, list the number of required visits for each service type (e.g., RN, PT, OT) along with the date ranges and required codes.
11. If you are requesting durable medical equipment, provide the HCPCS code, quantity, modifier, description, and cost in the DMEPOS section.
12. In the all other services section, enter the service type, required codes, diagnosis, CPT, requested start date, and the number of units/visits/days.
13. Lastly, add any additional comments if necessary, then review all information for accuracy.
14. Once completed, save changes, download, print, or share the form as needed.

Start filling out your forms online today to ensure a timely submission.