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Get () Prior Authorization Request Form ... - Optumrx
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How to fill out the ® () Prior Authorization Request Form - OptumRx online
Filling out the ® () Prior Authorization Request Form requires specific information to ensure prompt processing. This guide will provide step-by-step instructions to help you accurately complete the form online.
Follow the steps to successfully complete the form.
- Press the ‘Get Form’ button to access the ® () Prior Authorization Request Form and open it in your editor.
- Start by filling in the member information section. Required fields include the member's name, insurance ID number, date of birth, and complete address details.
- Next, proceed to the provider information section. Fill out the provider's name, NPI number, office phone, and address details as well.
- In the medication information section, provide the medication name and strength. Indicate whether this medication is a new start by selecting 'Yes' or 'No.'
- For the clinical information section, select the appropriate diagnosis. Options include breast cancer, infertility, or other diagnoses. Ensure to provide relevant ICD-9/10 codes where necessary.
- Answer the questions regarding the patient’s status for breast cancer or infertility and include any additional comments or important clinical information in the available space.
- Review the entire form to ensure all fields are filled out accurately and completely before submission.
- Finally, save your changes. You can download, print, or share the completed form as needed.
Complete your forms online today for a smooth and efficient submission process.
What is prior authorization? This means we need to review some medications before your plan will cover them. We want to know if the medication is medically necessary and appropriate for your situation. If you don't get prior authorization, a medication may cost you more, or we may not cover it.
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