Get Prior Authorization Criteria Form. Mvp Health Care Cigna Quick Reference Guide 3-12 - Healthplan

Filling out the Prior Authorization Criteria Form accurately is essential for ensuring timely approval of needed treatments. This guide provides a clear, step-by-step approach to help users navigate the form efficiently, promoting a smoother authorization process.

Follow the steps to accurately complete the Prior Authorization Criteria Form.

1. Press the ‘Get Form’ button to access the Prior Authorization Criteria Form and open it in a suitable editor.
2. Begin by entering the member's name in the designated field titled 'Member Name.'
3. Provide the member’s date of birth in the 'DOB' field.
4. Fill in the 'Member ID #' field with the appropriate identification number for the member.
5. Record the date on which you are completing the form in the 'Date' section.
6. Indicate the place of service where the treatment will take place by filling in the corresponding field.
7. Input the referral number in the designated 'Referral #' section.
8. Review the PRIOR AUTHORIZATION REQUIREMENTS section, checking all applicable criteria based on the patient's condition, such as TB test results and current treatments.
9. For treatments related to Crohn's Disease or ulcerative colitis, complete the required details regarding steroid treatment and responses.
10. If applicable, provide information on any previous trials with DMARDs or self-administered anti-TNF agents, including the name of the medication and trial dates.
11. In the PHYSICIAN INFORMATION section, enter the physician's name, address, telephone number, and contact person details.
12. Make sure the physician signs the form in the designated area to authenticate the request.
13. Finalize the form by saving any changes, and consider downloading or printing a copy for your records before sharing it.

Complete your Prior Authorization Criteria Form online to enhance your treatment process!