Get Caloptima Prior Bauthorization Formb - Caloptima

Filling out the CalOptima Prior Authorization Form can be streamlined by following this user-friendly guide. This document provides a step-by-step approach to completing the form accurately and efficiently.

Follow the steps to complete the CalOptima Prior Authorization Form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by entering patient information including the patient's name, CalOptima ID number, date of birth, and gender. Ensure that these details are clearly written to avoid any confusion.
3. Provide prescriber information, including the prescriber’s name, phone number, fax number, specialty, and NPI number. This information is crucial for processing the authorization request.
4. Indicate if there is any other primary insurance information for the patient, including the name of the primary insurance provider.
5. Fill out the patient location details. You can select from home, sub-acute, skilled nursing facility (SNF), or intermediate care facility (ICF).
6. Next, input pharmacy information, including the pharmacy name, NPI number, phone number, and fax number.
7. In the medication section, enter the drug name, National Drug Code (NDC), strength, directions, quantity, and the number of refills requested.
8. Provide the diagnosis or ICD-10 code that supports the medication request. This is necessary for the review criteria.
9. If applicable, offer a medical justification supporting the necessity of the requested medication. This should include any formulary drugs that have been attempted and justification for why the requested drug is required.
10. Finally, review all the entered information for accuracy. After confirming everything is correct, you can save your changes, download, print, or share the completed form as needed.

Start completing the CalOptima Prior Authorization Form online today for efficient processing.