Get Outpatient Prior Authorization Fax Form - Bridgeway Health Solutions

Filling out the Outpatient Prior Authorization Fax Form for Bridgeway Health Solutions is a crucial step to receive the necessary medications or treatments. This guide aims to provide clear instructions on how to properly complete the form to ensure an efficient authorization process.

Follow the steps to accurately complete your prior authorization fax form.

1. Press the ‘Get Form’ button to access the Outpatient Prior Authorization Fax Form and open it in your document editor.
2. Begin by filling out the member information section. Input the member's date of birth, member ID, and Medicaid ID in the required fields.
3. Proceed to the requesting provider information. Enter the requesting provider's NPI, TIN, full name, and contact information, ensuring that all required fields are filled.
4. Fill in the servicing provider or facility information. If it is the same as the requesting provider, you can check the appropriate box. Otherwise, complete the servicing provider NPI, TIN, name, and contact details.
5. In the authorization request section, enter the primary procedure code and corresponding diagnosis code. Make sure to provide required dates, such as start date or admission date.
6. Complete additional procedure codes if applicable, as well as the total units, visits, or days needed for the service.
7. Select the outpatient service type relevant to the request by filling in the square with an 'X'.
8. Review all sections for accuracy. You can save your changes, download the completed form, print it, or share it as needed.

Complete your Outpatient Prior Authorization Fax Form online today to ensure timely access to necessary services.