Get Long Term Care Prior Authorization Request - Uhccommunityplan.com

Filling out the Long Term Care Prior Authorization Request is an important step in ensuring that individuals receive necessary care. This guide provides clear instructions to help users complete the form accurately and efficiently.

Follow the steps to successfully complete the online form.

1. Click ‘Get Form’ button to access the Long Term Care Prior Authorization Request form and open it in the online document editor.
2. Begin by providing information about the requesting provider, including their name and the date of the request.
3. Fill in the patient information section, which includes the patient’s last name, first name, date of birth, and AHCCCS ID number.
4. Indicate whether Medicare or any other payer is the primary payer by selecting 'Yes' or 'No'. If 'Yes', you are not required to obtain prior authorization from UnitedHealthcare Community Plan for services.
5. For a 'No' response, proceed to indicate whether the request is urgent or routine by selecting the appropriate option.
6. Attach any relevant medical documentation, lab results, or drug history that may support the authorization request.
7. Provide details about the primary care provider, including their name, phone number, and AHCCCS ID number.
8. Complete the servicing provider information, including the service provider's name, specialty, contact details, and AHCCCS ID number.
9. Indicate the facility name and address where the services will be rendered, along with the NPI number.
10. Fill out the date of service, if scheduled, and provide relevant diagnosis codes and descriptions.
11. Check all applicable boxes for visit type (first-time consult or follow-up), procedure/service/surgery details, and provide CPT/HCPCS codes as necessary.
12. Note that prior authorization does not guarantee payment, and ensure that member eligibility is confirmed for the date of service.
13. Finally, provide any comments relevant to the request and indicate whether the authorization has been approved or denied in the designated section.
14. Save your changes, and when finished, download, print, or share the completed form as needed.

Begin filling out your Long Term Care Prior Authorization Request online today to ensure timely and accurate processing.