Get Body Pet Notification And Prior Authorization Fax Request Form

Filling out the Body PET Notification and Prior Authorization Fax Request Form online is an essential step in ensuring timely processing of your request. This guide provides detailed instructions to help you navigate each section of the form with ease.

Follow the steps to effectively complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editing interface.
2. Begin by filling out the 'Office Information' for the ordering provider. Include the date, office contact's name, phone number, and fax number. Specify the requesting provider's name and their phone number as well.
3. In the 'Request Type' section, indicate whether your request is urgent or routine. If selecting urgent, note that it indicates a significant impact on the health of the member if not completed within 72 hours.
4. Indicate which office you are representing by checking the appropriate box – 'Ordering' or 'Rendering'. If the rendering provider is completing the form, check whether the ordering provider is contracted to participate in the UnitedHealthcare Medicare Advantage or Medicaid network.
5. Move to the 'Member Information' section. Fill in the member's name, date of birth, member ID number, and member group number.
6. If applicable, provide 'Rendering Provider Information' for Medicare and Medicaid requests. This includes the rendering provider's name, federal tax ID number, phone number, fax number, and address.
7. In the 'Clinical Information' section, complete the CPT/HCPCS and ICD-9 codes as required. Include the requested CPT/exam and any necessary clinical data to support your request.
8. Detail the working diagnosis, any rule out conditions, cell type or tissue diagnosis, and the reason for the study. Be specific about initial staging, restaging, suspected recurrence, or other rationales for the examination.
9. Document any prior imaging results, current tumor markers, current symptoms, and findings from physical examinations.
10. Finally, review the form for accuracy. Once the form is complete, ensure it is signed by the appropriate provider. You may then fax the form along with any additional documentation to UnitedHealthcare at the specified fax number. For any questions, contact the provided helpline.

Complete your forms online today to ensure swift processing of your requests.