Get Request For Services Requiring Pre Authorization - Better Health

This guide will provide you with clear and supportive instructions on how to accurately complete the Request For Services Requiring Pre Authorization form for Better Health. Each section will be explained to help ensure the process is as seamless as possible.

Follow the steps to complete the form successfully.

1. Press the ‘Get Form’ button to obtain the form and open it in your document editor.
2. Begin by filling out the member's name, ensuring that all personal identifiers are correct.
3. Enter the member's ID number and date of birth in the provided fields.
4. Indicate whether the provider is in-network or out-of-network by checking the appropriate box.
5. Complete the referring physician's name, telephone number, and fax number as needed.
6. Fill in the diagnosis code (ICD-9), making sure it corresponds with the medical services requested.
7. List the CPT codes related to the services being requested.
8. Provide the reason for the referral to clarify the necessity of the services.
9. Specify the appointment date that aligns with the anticipated service.
10. Select the type of request by choosing either 'Standard' or 'Expedited/Urgent' and ensure to provide justification for urgent requests.
11. Indicate if the request is related to an accident, selecting 'YES' or 'NO' as applicable.
12. Note any other insurance coverage the member may have, specifying if Medicare or other insurance is applicable.
13. If applicable, complete the section about services needing pre-authorization and ensure to attach any supporting clinical documentation.
14. Once all fields are completed, save changes to your document. You can then download, print, or share the form as necessary.

Complete your documents online today to ensure timely processing of your request.