Get Standardized Prior Authorization Request Form Tufts

This guide provides a clear and supportive framework for filling out the Standardized Prior Authorization Request Form Tufts online. Understanding each section and field will help streamline your submission process for health plan requests, ensuring compliance with necessary requirements.

Follow the steps to complete the form effectively.

1. Press the 'Get Form' button to access the Standardized Prior Authorization Request Form and open it for filling out.
2. Fill in the health plan name and fax number to ensure the request is directed appropriately.
3. Indicate the date the form is completed and ready for submission.
4. Select the service types requiring authorization by checking all applicable boxes.
5. Provide the requesting and servicing provider's names along with their NPI numbers and contact details, ensuring required fields are marked.
6. Enter the member information including patient name, date of birth, health insurance ID, address, and contact number.
7. Detail the diagnosis or planned procedure information by describing the principal diagnosis and procedure, along with relevant ICD-10 and CPT/HCPCS codes.
8. Specify the number of units being requested for each procedure as per the guidelines—hours, days, or visits.
9. Complete the service start and end dates.
10. For any required supporting clinical documentation, ensure that attachments are included with the submission.
11. Review all information for accuracy, then proceed to save changes, download, print, or share the completed form.

Get started with your prior authorization requests online by completing the form today!