Get Trillium Outpatient Prior Authorization Fax Form

Filling out the Trillium Outpatient Prior Authorization Fax Form online is a straightforward process that ensures timely authorization for medical services. This guide will help you navigate each section of the form, making the completion as efficient and accurate as possible.

Follow the steps to complete your authorization request.

1. Click 'Get Form' button to obtain the form and open it in your editor.
2. Begin by filling in the member information section. This includes the member ID/Medicaid ID, date of birth, last name, and first name. Ensure that all required fields marked with an asterisk (*) are completed.
3. Next, move to the requesting provider information. Here, input the requesting NPI, TIN, contact name, phone number, and fax number. Again, ensure all required fields are filled in.
4. If applicable, indicate if the servicing provider/facility information is the same as the requesting provider. If not, fill in the servicing provider's NPI, TIN, contact name, phone number, and fax number.
5. In the authorization request section, fill in the primary and additional procedure codes, along with the start date or admission date and total units/visits/days required. Make sure to include the diagnosis codes as needed.
6. Select the appropriate outpatient service type by entering the corresponding service type number. Complete all additional procedure codes and diagnosis codes as necessary.
7. Review all entries for accuracy and completeness. Submit all supporting clinical information as required, making sure every necessary field is filled in to avoid rejection.
8. Once you have completed the form, you may choose to save changes, download, print, or share the completed form for faxing.

Start the process of completing your Trillium Outpatient Prior Authorization Fax Form online today!