Get Prior Authorization Form - Providers - Arbor Health Plan Prior Authorization Form

Filling out the Arbor Health Plan Prior Authorization Form online is a straightforward process that requires careful attention to detail. This guide will lead you through each section of the form, ensuring that you complete it accurately for efficient processing.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by completing the patient information section. Include the patient's name, Medicaid ID or RID number, date of birth, address, city, ZIP code, state, and a contact phone number for the patient or guardian.
3. Next, fill in the provider ordering or providing service section. Enter the requesting provider's NPI number, tax ID number, service location code, provider name, provider address, city, phone number, state, ZIP code, and fax number.
4. In the facility providing service or equipment section, repeat the entry of the requesting provider's NPI number, tax ID number, provider name, provider address, city, state, phone number, and ZIP code, along with the fax number.
5. You will then provide a medical diagnosis by using ICD-10 diagnostic codes. Fill in up to three ICD-10 DX codes as applicable.
6. Indicate the type of service by checking the relevant option(s) such as durable medical equipment, new concurrent review, office visit, home health care, discharge planning, outpatient, inpatient, discharge notification, or other.
7. Add the preparer's information in the next section by providing their name, phone number, and fax number.
8. Specify the dates of service, including the start and stop dates.
9. Provide procedure or service codes along with a description of the requested service and the number of units requested.
10. Ensure to check the box if you are attaching documentation to support medical necessity and include any additional comments as needed.
11. Finally, sign the form by entering the signature of the person preparing the form or qualified personnel, along with the date.
12. Once all information is completed, you can save changes, download, print, or share the form as required.

Complete your Prior Authorization Form online today for timely processing.