Get South Carolina Prior Authorization Fax Request Form

In this guide, you will learn how to accurately complete the South Carolina Prior Authorization Fax Request Form online. Ensuring that you fill out every section correctly is crucial for expediting your authorization request process.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to retrieve the South Carolina Prior Authorization Fax Request Form and open it in your preferred editing tool.
2. Enter the date at the top of the form. Include the contact person's name and their phone number, as well as the relevant fax number. Indicate if the fax line is HIPAA secure by checking the appropriate box.
3. Fill in the requesting provider’s information, including their name and TIN/NPI number.
4. In the member information section, provide the member's name, ID number, and date of birth. Indicate if the member is pregnant, relates to a motor vehicle accident or work-related injury, and if they have other insurance. If applicable, provide details of other insurance, including the name and policy number.
5. Select the type of request by checking the relevant box: Routine, Expedited/Urgent, Inpatient, Outpatient, or Home.
6. For the servicing provider and facility information, fill out the servicing provider's name, TIN/NPI, and address. Include the servicing facility's information, ensuring to specify if they are in or out of network. If applicable, indicate whether the out of network provider will accept Medicaid/Medicare default rate.
7. In the clinical information section, list the diagnoses, ICD-9 codes, and required CPT/HCPCS codes. Provide any necessary descriptions for miscellaneous and/or unlisted codes and detail the number of visits, start and end dates, frequency, and DME cost.
8. If there are previous visits or service descriptions, include that information with the corresponding CPT/HCPCS codes.
9. Once all sections of the form have been completed, review the information for accuracy. You can then save your changes, download the completed form, print it, or share it as needed.

Complete the South Carolina Prior Authorization Fax Request Form online today for efficient processing of your request.