Get Pre-authorization Request Form Phone: 800-882 ... - Healthcare Usa

Filling out the Pre-Authorization Request Form is essential for ensuring timely approval of necessary medical services. This guide will provide detailed steps to assist you in accurately completing the form online, making the process smooth and efficient.

Follow the steps to effectively complete the Pre-Authorization Request Form.

1. Click 'Get Form' button to access the Pre-Authorization Request Form and open it in a suitable editor.
2. Begin by selecting the type of request. Indicate whether the request is 'Urgent for acute care within 48 hours' or 'Non-Urgent for routine, elective services'. Mark the appropriate box for either 'Inpatient' or 'Outpatient'.
3. Provide the patient information. Fill in the patient's last name, first name, middle initial, identification number, and indicate if they have other insurance coverage by selecting 'Yes' or 'No'. If applicable, list the name of the insurance carrier.
4. Next, specify if the request is related to a job injury or a motor vehicle accident by checking the 'Yes' or 'No' options.
5. In the 'Requesting Provider' section, print the name of the requesting provider, their date of birth, gender, and tax identification number. Include the contact person's name, telephone number, and fax number from the requesting provider's office.
6. Provide details about where services will be rendered by listing the physician, provider, or facility requested. Include their address, telephone number, and fax number.
7. Indicate today's date and the tentative date of service or admission. If therapy services are requested, provide the first treatment date.
8. Complete the clinical information section by entering the required ICD-9 codes and their corresponding diagnosis descriptions. Also, include the date of onset or injury.
9. Enter the necessary CPT/HCPC codes and describe the services requested, as well as the number of days or visits required.
10. Fill out the clinical indications/rationale for the request. Attach relevant clinical documentation and medical records to support the request, and check the box indicating if attachments are included.
11. Finally, note the total number of pages faxed, including the completed request form.
12. Once all sections are complete, save your changes and download or print the form for submission as needed.

Start filling out your Pre-Authorization Request Form online today to ensure timely processing of your request.