Get Pre-authorization Request Form - Intotal Health

Filling out the Pre-Authorization Request Form is an essential step in ensuring timely access to necessary medical services. This guide provides a clear, step-by-step approach to completing the form online, helping you navigate each section effectively.

Follow the steps to fill out the form accurately.

1. Press the ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter today’s date in the designated field to document when the request is being submitted.
3. Fill in the provider return fax number to ensure that the information can be correctly routed back to your office.
4. Complete the member information section by including the person's full name, date of birth, address, city, state, ZIP code, Medicaid number, and any other insurance or workers' compensation details.
5. Provide referring provider information including their name, Medicaid provider number, office contact name, NPI, TIN, phone number, and an alternative phone number.
6. If applicable, fill out the rendering practitioner section which includes their last name, first name, provider specialty, NPI, TIN, phone, fax, address, city, state, and office contact name.
7. Complete the rendering facility section if needed, including the facility name, NPI, TIN, phone, fax, address, city, state, and office contact name.
8. List the requested services by entering the date(s) of service, ICD-9 code/diagnosis/reason for referral, CPT/HCPCS/RV code(s), and the number of visits/units requested.
9. Provide any previous medical history, studies, or treatments in the PMH section.
10. Specify the service location as either inpatient, outpatient, extended stay, home, office, or other.
11. Indicate the service type as durable medical equipment, home health, hospice, or other, if applicable.
12. For maternity care, note whether this is an initial notification of pregnancy or related services, ensuring to use the correct forms as needed.
13. Attach any necessary clinical information to support the medical necessity for the services requested.
14. Once the form is completed, save changes, download for your records, print, or share it as required.

Take action now by completing your Pre-Authorization Request Form online to facilitate timely healthcare support.