Get 047 Preauthorization Request Form For Surgical Management Of Obesity Mp 379.doc

Filling out the 047 Preauthorization Request Form is essential for patients seeking surgical management of obesity. This guide aims to provide clear, step-by-step instructions on how to complete the form online, ensuring accurate submissions for preauthorization.

Follow the steps to successfully complete your preauthorization request form.

1. Click the ‘Get Form’ button to access the form and open it in an online editing tool.
2. Fill in the patient information section. You will need to provide the patient's name, today's date, BCBSMA ID number, date of surgery, date of birth, height, weight, blood pressure, and current BMI.
3. Provide the physician's information, including the physician's name and any necessary facility information. Ensure to include the complete address and contact details.
4. Select the procedure information based on the diagnosis code that matches the patient's condition. You must check the appropriate boxes for their Body Mass Index (BMI) and any additional diagnoses.
5. Choose the relevant procedure codes from the list provided. Review each option carefully to select the correct surgical procedure intended for the patient.
6. Indicate the patient's selection criteria by checking the boxes for co-morbid conditions if applicable. This section may play a crucial role in determining medical necessity.
7. Complete the section regarding the physician's remarks about the patient, including motivation and previous weight loss attempts.
8. Once you have filled out all required fields, review the completed form for accuracy. Make necessary adjustments if required.
9. Save your changes and choose to download, print, or share the form as needed before submitting it to the specified fax number.

Complete your preauthorization request form online today for a streamlined submission process.