Get Mysmarthealth

This guide provides a step-by-step approach to filling out the Mysmarthealth pre-certification form online. Whether you are a first-time user or have experience with digital document management, this comprehensive guide will help you navigate the required fields with ease.

Follow the steps to complete the Mysmarthealth form online.

1. Press the ‘Get Form’ button to access and open the pre-certification form in an online editor.
2. Fill in the requesting provider information, including the request date, contact name, and specify if the request is elective, direct/urgent, or emergent. Enter the provider's phone number and fax number for correspondence.
3. Input the requesting provider’s name and specialty in the designated fields.
4. Complete the patient information section by entering the patient name and date of birth. Also, fill out the subscriber name and subscriber ID number.
5. Detail the requested services by entering the requested provider's name, address, NPI number, phone number, and fax number.
6. If applicable, fill out the facility information, including whether it is an inpatient or outpatient service, along with the address, NPI number, phone number, and fax number.
7. Provide the date of service information required for the requested procedures.
8. List the diagnosis and corresponding ICD-9 codes for each diagnosis.
9. Document the procedures needed with their corresponding CPT4 codes.
10. If requesting TIER2 coverage, check the appropriate box to confirm there are no available TIER1/TIER2 providers within a 50-mile radius.
11. Attach any relevant clinical information or reports, ensuring all applicable data is included.
12. Do not fill in the office use section, as it is reserved for authorized personnel.
13. Once all sections are completed, you can save changes, download the form, print it, or share it as needed.

Start filling out your Mysmarthealth pre-certification form online today.