Get Unison Medplus Prior Authorization Program Exception Form

Navigating the Unison MedPLUS Prior Authorization Program Exception Form can seem daunting, but this guide provides clear instructions to help you complete it online efficiently. By following each step, you will ensure that all necessary information is accurately submitted.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to access the form and open it in the document editor.
2. Enter the ID number in the designated field provided at the top of the form.
3. Fill in the last name and first name of the individual for whom the prior authorization is being requested.
4. Provide information for the requesting practitioner by entering their ID number, telephone number, and any other relevant details.
5. Similarly, input details for the service practitioner, including their ID number and telephone number.
6. Complete the street address, city, state, and zip code sections to indicate the member's current residence.
7. Specify the type of current residence, such as skilled nursing facility (SNF) or personal care home (PCH).
8. Detail the primary diagnosis and include the corresponding ICD-9 code.
9. If applicable, provide a secondary diagnosis with its ICD-9 code.
10. Describe the service requested and any associated code(s) or billable charges.
11. Indicate the requested date of service and the estimated length of need for the requested service.
12. List any alternative treatments utilized prior to this request in the specified section.
13. Provide a brief narrative describing the symptoms or abnormalities that the requested service intends to alleviate, including medical justification.
14. If applicable, attach a copy of the manufacturer’s specification sheet and the suggested retail price per unit/item for durable medical equipment (DME) items.
15. Ensure the ordering physician's signature and date are included at the end of the form.
16. Once all fields are correctly filled out, save changes, download, print, or share the form as needed.

Complete your Unison MedPLUS Prior Authorization Program Exception Form online to ensure a smooth approval process.