Get Preauthorization Request Form - Rocky Mountain Health Plans - Rmhp

Filling out the Preauthorization Request Form is an essential step in ensuring that necessary medical services are preauthorized by Rocky Mountain Health Plans. This guide provides clear instructions on how to accurately complete the form online, helping users navigate each section effectively.

Follow the steps to accurately complete the Preauthorization Request Form online:

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. Select whether this is a new request or a revised request by marking the appropriate checkbox.
3. Fill in the patient’s full name along with their member ID number and date of birth.
4. Provide the requesting provider’s full name, phone number, and fax number.
5. Input the billing provider’s full name, Tax Identification Number (TIN), phone number, and fax number.
6. Indicate the facility or office where the service will be performed, including the address and phone number.
7. Designate a contact person for determination notifications along with their phone number.
8. Choose the type of services requested by checking the relevant boxes, such as inpatient surgery or outpatient surgery.
9. If applicable, specify the organ involved for transplant evaluations or listings.
10. Enter the date of service and fill in the diagnosis code and description.
11. List any relevant CPT or HCPCS codes, along with the name and quantity of services requested.
12. Indicate if a surgical assist is requested and provide their credentials if applicable.
13. Add a detailed description of the requested services.
14. For medication orders, provide the name of the pharmacy, store number, and full address.
15. After completing all required fields, ensure to attach the necessary clinical notes and save changes to the form.

Complete your Preauthorization Request Form online today to ensure timely processing of your medical services.