Get & Prior Authorization Request Form ... - Optumrx

Completing the & Prior Authorization Request Form is an essential step in ensuring that the necessary medication is provided efficiently. This guide will walk you through each section of the form, offering clear and detailed instructions to help simplify the process for all users.

Follow the steps to complete the authorization request form.

1. Press the ‘Get Form’ button to obtain the authorization request form and open it for filling out.
2. Begin by filling out the member information. This section requires details such as the member's name, insurance ID number, date of birth, and address. Ensure accuracy to prevent processing delays.
3. Next, provide provider information by entering the provider's name, NPI number, office phone number, and address. Make sure to include the specialty for better clarity.
4. In the medication information section, specify the medication name and its strength, and indicate if this is a new start. Additionally, fill in dosage form and directions for use.
5. Move to the clinical information section and select the appropriate diagnosis from the options provided. If applicable, add any other diagnosis along with the appropriate ICD-9/10 codes.
6. Acknowledge any risks if the provider is considering this medication for individuals aged 65 and over. Additionally, confirm that no other drug can effectively meet the needs of the patient.
7. List any medications that the member has failed, had contraindications for, or experienced intolerances to. Providing this information helps support the authorization request.
8. In the quantity limit requests section, specify the quantity requested per day and the reason for exceeding plan limitations. It is essential to provide valid reasons for faster approval.
9. Finally, include any additional comments, diagnoses, symptoms, or other important information that the physician believes is necessary for the review.
10. Once you have completed the form, you can save your changes, download the completed form for your records, print a hard copy, or share it as needed.

Complete your prior authorization requests online for a smoother experience.