Get Mdwise Marketplace Prior Authorization Form - Providers - Mdwise ... - Hoosieralliance

Filling out the MDwise Marketplace Prior Authorization Form is a crucial step in requesting medical services. This guide offers step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to effectively complete the prior authorization form.

1. Press the ‘Get Form’ button to access the MDwise Marketplace Prior Authorization Form and ensure it opens in your editing application.
2. Begin by filling out the member information section, which includes entering the member’s first name, last name, MDwise Marketplace ID, and date of birth accurately.
3. Complete the requesting provider information by providing the first and last name, address, city, state, zip code, phone number, and extension if applicable.
4. In the servicing provider information section, enter the corresponding details including the first and last name, address, phone number, NPI number, LPI number, group tax ID, and fax number.
5. Next, in the diagnosis information section, provide the relevant diagnosis codes and descriptions for the medical service requested.
6. Fill out the procedure information section by entering the date of the procedure or service, service codes, start and stop dates, modifiers, type of service, units or visits required, and dollar amounts for DME only.
7. Finally, ensure to attach any necessary supporting clinical documentation to your prior authorization request, as outlined in the form instructions.
8. Once all required fields are completed, you may save the changes, download the form, print it out for your records, or share it as needed.

Complete your MDwise Marketplace prior authorization forms online today for a streamlined request process.