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  • Diagnostic Imaging Pre-authorization Exam Requisition Form

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Pre-Authorization Request Form for Diagnostic Imaging Procedures 1. Please call (201) 447-8200 to schedule your patient s procedure, then 2. Fax the completed form, along with a signed prescription.

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Authorization is not required for procedures performed in an emergency room, observation unit, urgent care center or during an inpatient stay. *Note: For Medicare Advantage benefit plans, prior authorization is not required for CT, MRI, or MRA.

Retroactive Authorization request: • Authorization will be issued when due to eligibility issues. after an appeal is filed. UHC often doesn't receive complete clinical information with an authorization to make a medical necessity determination.

Requisition forms, sometimes called referral forms, are used by your doctor or local physician to communicate precisely what type of exam you require for a medical assessment. These forms direct our technologists by outlining where diagnostic imaging is needed, such as your left shoulder or right ankle.

Prior authorization, or preauthorization, is a process through which health care providers obtain coverage approval from health plans prior to performing certain non-emergency procedures. It can also be an important “checkpoint” to make sure a service or prescription is a clinically appropriate option.

Insurance companies often will agree to cover MRIs if patients obtain pre-approval for the imaging. This process, called prior authorization, entails giving the insurer additional information about why the doctor has prescribed the scan and what circumstances, such as an injury, led to the order.

Notification should be submitted as far in advance as possible but must be submitted at least five business days before the planned service date (unless otherwise specified). It may take up to 15 calendar days to receive a decision (14 calendar days for UnitedHealthcare Medicare Advantage plans).

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232