Get Imo Pre-authorization Non-network Request Form

This guide will assist users in accurately completing the IMO Pre-Authorization NON-NETWORK Request Form online. With clear instructions for each section, users can ensure their requests are correctly submitted.

Follow the steps to complete the online form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in your chosen editor.
2. Enter the patient's information in the Claim Profile section. This includes the patient's name, phone number, address, city, date of injury, date of birth, state, zip code, and the last four digits of their Social Security Number.
3. Provide the employer's name and the claim number. Additionally, fill in the details for the insurance carrier and adjuster, including their name.
4. In the Treating Provider section, input the provider's name, address, city, tax ID number, NPI number, phone number, fax number, state, zip code, and contact name.
5. For the Requesting Provider section, provide similar details as in the Treating Provider section, ensuring to include the email address for determination letters.
6. In the Facility Information section, enter the facility's name, address, city, tax ID number, NPI number, phone number, fax number, state, zip code, and contact name, along with the respective email address.
7. Under Service Request/Type of Review, specify the requested procedure or body part, expected dates of service, and whether the request is for in-patient or out-patient care.
8. Indicate the frequency and duration of the service being requested, and provide the relevant ICD-9 codes as well as CPT codes if applicable.
9. Fill out the Peer-to-Peer Contact Name section if different from the requestor, including a phone number and hours of availability.
10. Ensure to include all supporting clinical documentation to validate the request before finalizing.
11. Once all fields are completed, review the entire form for accuracy, then save your changes, and choose whether to download, print, or share the form as needed.

Complete your IMO Pre-Authorization NON-NETWORK Request Form online today for a smooth submission process.