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Get Request For Services Requiring Prior ... - Simply Healthcare Plans
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How to fill out the Request For Services Requiring Prior Authorization - Simply Healthcare Plans online
This guide provides comprehensive, step-by-step instructions for completing the Request For Services Requiring Prior Authorization for Simply Healthcare Plans. It is designed to assist users in accurately filling out the necessary information to facilitate their service requests.
Follow the steps to correctly complete the form online.
- Press the ‘Get Form’ button to access the form and open it for editing.
- Start by filling in the member name in the designated field. Ensure that the full name matches the name on the insurance card.
- In the 'Referred to' section, enter the name of the provider to whom the member is being referred.
- Circle the plan name that applies to the member. In this case, select either Simply Better or Clear Health.
- Specify the specialty of the referral next to the 'Specialty' field.
- Input the Health Plan ID number in the corresponding field to help identify the member's account.
- Enter the member's date of birth in the 'Member DOB' section, using the specified format.
- Provide the member's phone number in the appropriate field.
- Fill in the 'Referred to Fax #' with the provider's fax number.
- Include the Primary Care Physician (PCP) name and their ID number.
- Document any diagnosis codes using the ICD-10 format under the 'Diagnosis (ICD-)' section.
- Enter the CPT codes related to the services being requested.
- Complete the section for referring physician information, including their name, phone number, and fax number.
- Select the request type as 'Standard' or 'Expedited/Urgent' and provide justification for urgent cases.
- Indicate if the request is related to an accident and if the member has other insurance coverage.
- Make sure to check all necessary box options for services requiring pre-authorization and attach any additional documentation.
- After filling out all sections, review the entire form for completeness and accuracy.
- Finally, save your changes and choose to download, print, or share the completed form as needed.
Complete your documents online efficiently and accurately.
Our Medicaid and Florida Healthy Kids plans Simply serves members in Florida's Statewide Medicaid Managed Care Managed Medical Assistance (MMA) and Long-Term Care (LTC) programs, as well as members enrolled in Florida Healthy Kids.