Get Bcbstn - Pm Req Frm-fnl--2016x 52274 - Activated Traditional

This guide provides clear, step-by-step instructions for completing the BCBSTN - PM Req Frm-FNL--2016X 52274 - Activated Traditional form online. Ensuring accuracy in your submission will help expedite your request for prior authorization of pain management services.

Follow the steps to accurately complete the prior authorization request form.

1. Click the ‘Get Form’ button to obtain the form and access it in your chosen online editor.
2. Begin by filling out the patient information section. Input the patient's first name, last name, date of birth, BCBST member ID number, and any relevant prefixes or suffixes as needed.
3. Next, move to the pain management provider information section. Fill in the treating provider's name, address, state, city, telephone number, provider ID or NPI number, and tax identification number.
4. Proceed to the referring provider information section. Here, you will input the name, address, city, state, telephone number, and provider identification numbers of the referring provider.
5. In the request information section, begin by entering the primary diagnosis code using ICD-10 format. Then select the appropriate spinal region(s) that apply.
6. Specify the requested procedures by selecting from the various listed options, such as spinal cord stimulators or pain pumps.
7. Provide exact details on the injection sites, including whether they will be left, right, or bilateral, and the site of injection. This information is vital for processing the request.
8. Indicate how many injections have occurred in the past 12 months and provide the date of the last injection.
9. Complete the CPT codes, place of service, and anticipated date of service sections as required.
10. After filling out all sections accurately, review your entries for completeness before saving changes or sharing the form as necessary.

Start filling out your pain management prior authorization request form online today to ensure timely processing.