Get Rtms Prior Authorization Request - Health New England

Completing the RTMS Prior Authorization Request form for Health New England is a crucial step in obtaining approval for treatment. This guide provides clear, step-by-step instructions to ensure that users can effectively fill out the form online.

Follow the steps to successfully complete your authorization request.

1. Click ‘Get Form’ button to access the RTMS Prior Authorization Request form and open it in your preferred document editor.
2. Fill out Section A with the patient's information. Enter the date, patient name, patient ID, and patient date of birth accurately to ensure proper identification.
3. Proceed to Section B for referral details. Input the referring provider's name and HNE provider ID. Include the provider's address and contact information, as well as the details for the rTMS provider.
4. In Section C, provide the reason for the referral. Specify the mental health diagnosis, treatment history, and psychiatric medication history. Ensure to state if the member has undergone a trial of Electroconvulsive Therapy (ECT) and provide details as required.
5. Confirm the treatment-resistant depression criteria by answering the necessary questions with 'yes' or 'no.' Ensure that each checkbox corresponds to the member's treatment history and current status.
6. Review all sections of the form to ensure that all relevant clinical documentation is attached to support the request before submission.
7. Once completed, save the changes to maintain your entries. You may also download, print, or share the form as needed to submit it to the HNE Behavioral Health Department.

Begin filling out your RTMS Prior Authorization Request form online today to streamline your authorization process.