Get Permanente Advantage Authorization Request Form Instructions - Providers Kaiserpermanente

Filling out the Permanente Advantage Authorization Request Form is a vital step for healthcare providers seeking pre-authorization for services. This guide provides a clear, step-by-step approach to assist you in completing the form accurately and efficiently.

Follow the steps to fill out the Permanente Advantage Authorization Request Form online.

1. Press the ‘Get Form’ button to access the authorization request form and open it for editing.
2. Begin by completing the top portion of the form. Enter your name, phone number, fax number, and office details. Include the patient's name, date of birth, and their Kaiser Medical Record Number (MRN) found on their insurance card.
3. Submit recent supporting documents such as the history and physical (H&P) report, clinical notes, and physician’s order. Ensure that these documents are legible, either dictated or typed, to avoid delays.
4. For requests involving Durable Medical Equipment (DME), prosthetics, or orthotics, include the pricing information with your submission.
5. You must provide Diagnosis Codes and Procedure Codes (CPT or HCPCS) related to the request.
6. Fill in the details for the Requesting Provider (Physician). Include their name, mailing address, phone number, and Tax ID or NPI number.
7. Complete the section for Place of Service/Servicing Provider, detailing the facility or provider who will perform the procedure. Enter their mailing address, phone number, and Tax ID.
8. Once all information is completed, fax the entire form along with the supporting documentation to 1-866-338-0266. Consider the timeframes for review: two business days for non-urgent requests and one business day for urgent cases.
9. Finally, download or print a copy of the completed form for your records or future reference.

Complete your Permanente Advantage Authorization Request Form online to ensure timely processing for your patient.