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Get Husky Health Programprovidersprenatal Testing For Fetal Aneuploidy Prior Authorization Request Form
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How to fill out the HUSKY Health Program Providers Prenatal Testing For Fetal Aneuploidy Prior Authorization Request Form online
This guide offers clear instructions on completing the HUSKY Health Program Providers Prenatal Testing For Fetal Aneuploidy Prior Authorization Request Form online. By following these steps, users can ensure that all necessary information is accurately provided for the required authorization.
Follow the steps to complete the form successfully.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by filling out the member information section. Enter the Member ID number, Date of Birth (DOB), Address, Member Name (Last, First), and City, State, Zip.
- In the requested testing section, input the CPT Code, Date of Service, Diagnosis (ICD-10 CM) Code(s), and Estimated Date of Confinement (EDC).
- Answer the questions regarding pregnancy risk factors by selecting 'Yes' or 'No' for each item, which includes maternal age, ultrasound findings, prior pregnancy history, screening results, and parental translocation.
- Confirm that the risks and benefits of testing have been discussed with the patient by checking the appropriate box.
- Fill in the billing provider information, including Medicaid Billing Number, Billing Provider Name, Street Address, Phone Number, City, State, Zip, Fax Number, and Contact Name.
- Next, provide the ordering provider information in the same format as the billing provider information.
- Review the certification statement, ensuring that all entries are accurate. The ordering provider must sign and date the form.
- Once the form is completed, save changes, and you can opt to download, print or share the filled form as needed.
Complete your documents online today to ensure timely processing!
Most insurance plans cover prenatal testing, especially for women over 35 years of age. You may need a referral from your primary care physician or health plan for your health insurance to cover the services.
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