Get Proactive Benefit Review

The Proactive Benefit Review is an essential tool for efficiently managing prior authorization requests. This guide provides a step-by-step approach to filling out the form online, ensuring all required information is accurately documented.

Follow the steps to successfully complete the Proactive Benefit Review form.

1. Press the ‘Get Form’ button to download the Proactive Benefit Review document and open it in your preferred editor.
2. Begin by filling out the member information section. Ensure to include the member's full name, date of birth, and insurance ID number.
3. Next, provide the necessary provider information. This includes the provider's name, NPI number, office phone, and office address, including street, city, state, and zip code.
4. In the medication information section, input the medication name, strength, and select any applicable checkboxes regarding the brand request or continuation of therapy.
5. Complete the clinical information section. Mark if this is a proactive request for a 2019 benefit determination and provide the patient’s diagnosis along with the relevant ICD-10 code.
6. Outline any medications the patient has previously tried, noting their effectiveness, and specify any contraindications or intolerances to medications.
7. If applicable, include any supporting laboratory or test results that pertain to the review.
8. Specify the requested quantity of medication per day and provide reasoning for exceeding any plan limitations, marking applicable options and providing additional details as necessary.
9. Add any other relevant comments or information that the physician deems necessary for the review.
10. Once all sections are thoroughly completed, save your changes. You may download or print the form, or share it as required to finalize the submission.

Complete your Proactive Benefit Review online to streamline your prior authorization requests.