PRECERTIFICATION REQUEST FORM Fax completed form to 6028643126, or email to pharmacyprecert azblue.com. Call 8663251794 to check the status of a request. All fields must be completed and legible for.
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How to fill out the PRECERTIFICATION REQUEST FORM - AZBlue online
This guide provides comprehensive instructions on completing the PRECERTIFICATION REQUEST FORM - AZBlue online. By following these steps, users can ensure that they accurately provide all necessary information for their request.
Follow the steps to complete the form effectively.
- Click ‘Get Form’ button to access the PRECERTIFICATION REQUEST FORM - AZBlue and open it for editing.
- In Section 1, fill in the prescribing provider's information, including their name, specialty, address, phone number, fax number, NPI, and email address.
- Move to Section 2 where you will provide patient information. This includes the patient's first and last name, date of birth, and BCBSAZ ID. Ensure clarity as this form does not apply to FEP or other Blues Plans.
- In Section 3, input medication information, specifying the medication name (), dosage directions, ICD-10 code, form (capsule), strength (100 MG, 200 MG, or 300 MG), duration of use, and diagnosis description.
- Address all questions in Section 4, ensuring that all relevant information that supports the request is included. This section requires detailed medical history and conditions regarding neurogenic orthostatic hypotension. Answer all questions accurately, as this is critical for the assessment.
- In Section 5, the prescribing provider must sign and date the form, affirming that all provided information is true and accurate.
- Lastly, choose the turn-around time for review in Section 6 by checking the appropriate option: standard, urgent, or exigent.
- Once all fields are completed and reviewed for clarity and accuracy, save the form changes, and prepare to either download, print, or share the completed document.
Complete your PRECERTIFICATION REQUEST FORM - AZBlue online today to ensure a smooth and efficient submission process.
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What is the electronic payer ID for BCBS of Arizona?
Submit claims electronically to BCBSAZ (EDI Payer ID: 53589).
Does Blue Cross Blue Shield of Michigan require prior authorization?
BCBSM requires prior authorization for services or procedures that may be experimental, not always medically necessary, or over utilized. Providers must submit clinical documentation in writing explaining why the proposed procedure or service is medically necessary.
How do I contact Blue Cross Blue Shield of Arizona?
Call your closest office: (602) 864-4884, or toll-free (800) 232-2345, ext. 4884 Do you speak Spanish? Our service department does, too.
How do I submit a claim to BCBS of Arizona?
To submit your claim, mail your completed form and corresponding provider statement to: BLUE CROSS BLUE SHIELD OF ARIZONA. P.O. Box 2924. Phoenix, AZ 85062.
What is the fax number for BCBS Arizona prior authorization?
Fax to BCBSAZ-Neighborhood HMO at: 1 (844) 263-2272 Type of request (select one): PCP Referral to Specialist – only complete sections 2 through 5 on page 1 of this form. SAVE and FAX to 1 (844) 263-2272. Precertification Request – all of the following information and documentation is required.
What is the timely filing for BCBS Arizona?
Initial Claim: 6 months from the date of service (If HCP is primary, the claim timeliness changes to 7-months from the date of service or eligibility date). Corrected Claim: 12 months from the date of service. Corrected Claim:12 months from the date of service.
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