Get Prior Authorization Request - Uhccommunityplan.com

Completing the Prior Authorization Request form is an essential step in securing the necessary approvals for services within the UnitedHealthcare Community Plan. This guide provides a clear, step-by-step approach to filling out the online form accurately and effectively.

Follow the steps to successfully complete the Prior Authorization Request.

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. Fill in the date of the request at the top of the form. Choose if the request is urgent by selecting 'Yes' or 'No.' If urgent, ensure you provide the correct phone numbers for QUEST and QExA for immediate assistance.
3. In the member information section, print the patient's name, member ID number, date of birth, home address, city, state, and ZIP code. Also, provide a contact phone number.
4. Enter the referring physician's information, including their name, specialty, contact person's name, phone number, and fax number. Ensure to include the physician's or authorized person's signature.
5. Next, input the servicing provider's details—name, specialty, address, phone number, office contact name, and fax number. Specify the service setting (IP, OP, office, or other) and provide the facility name.
6. Clearly indicate the date of service. If this is an initial request for physical therapy, occupational therapy, or speech therapy, mark accordingly. For continuing services, provide the last date of service.
7. If applicable, specify the number of visits requested for ongoing therapy and include documented reasons for the request.
8. Attach any clinical notes or documentation that illustrate the medical necessity for the requested services, along with the corresponding ICD9-CM codes and CPT/HCPC codes relevant to the procedure or treatment.
9. Indicate if durable medical equipment (DME) is required. If renting, specify the number of visits or units needed and provide a medical order. If purchasing, ensure all relevant medical documents are included.
10. After completing the form, review all information for accuracy. Users can then choose to save changes, download the form, print it, or share it as needed.

Complete your Prior Authorization Request form online today for a seamless process.