Get Mdwise Marketplace Prior Authorization Form Please ... - Mdwise

Completing the MDWISE Marketplace prior authorization form is essential for obtaining authorization for medical services. This guide provides clear and step-by-step instructions to help you navigate through the form efficiently and accurately.

Follow the steps to complete the authorization form successfully.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by filling out the 'Member Information' section with the following required details: First Name, Last Name, MDwise Marketplace ID, and Date of Birth.
3. Next, move to the 'Requesting Provider Information' section. Input the Requesting Provider's First Name, Address, City, and Phone Number. Make sure to include the Contact Name as well.
4. Proceed to the 'Servicing Provider Information' section and fill in the details for the Servicing Provider, including their First Name, Last Name, Address, City, State, Phone Number, NPI Number, and Tax ID.
5. In the 'Diagnosis Information' section, enter the relevant Diagnosis Codes and descriptions. Ensure all necessary codes are documented clearly.
6. For the 'Procedure Information,' provide the Date of Procedure/Service, relevant Service Codes, Start and Stop dates, Modifiers, Type of Service, and Units/Visits. Insert any applicable Dollars/Purchase/Rental values.
7. Attach any clinical documentation that supports your prior authorization request. For behavioral health requests, ensure to include copies of the initial assessment, treatment plan, and the last three progress notes. Additionally, include a list of tests requested and hours for psychological testing.
8. After completing all sections, review the information for accuracy and completeness before submitting.
9. Finally, save your changes, and then choose to download, print, or share the form with the appropriate MDwise Delivery System fax number as indicated.

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