Get Dhsoha Prior Authorization Request Form

Filling out the DHSOHA Prior Authorization Request Form online can streamline the process of obtaining necessary approvals for medical services. This guide provides clear, step-by-step instructions to help users navigate the form with ease and confidence.

Follow the steps to successfully complete your request form.

1. Click ‘Get Form’ button to obtain the form and open it in your chosen editor.
2. Enter the requesting provider name along with the provider number. Include a contact name, their phone number, and fax number to ensure efficient communication.
3. Choose the processing time frame based on urgency: routine, urgent, or immediate. If urgent or immediate is selected, provide a supporting justification.
4. Indicate the type of prior authorization request by checking the appropriate assignment code box relevant to your request.
5. Fill in the client ID and personal details, including the last name, date of birth, first name, and middle initial.
6. For service information, attach relevant documentation justifying the services requested. This may include treatment plans, progress notes, and invoices as necessary.
7. Provide details about the primary diagnosis and its corresponding code, along with any other pertinent diagnosis codes.
8. If services are to be performed in a facility, include the facility name and provider number, along with any revenue codes.
9. Complete the line item information by detailing each procedure code, its modifier, description, units, MSRP, and total cost.
10. For dental requests, include the tooth number and quad. If applicable, add pharmacy information such as drug name, strength, quantity, NDC, and directions.
11. Provide performing provider details including their name, provider number, and contact information.
12. Enter the date of request along with the expected service begin and end dates.
13. Review all fields to ensure accuracy. Finally, save changes, download, print, or share the completed form as needed.

Complete your DHSOHA Prior Authorization Request Form online today to ensure timely processing.