Get Husky - Advanced Imaging Prior Authorization Request Form - Huskyhealthct

Filling out the HUSKY - Advanced Imaging Prior Authorization Request Form online is a straightforward process. This guide provides step-by-step instructions to help you navigate the form and ensure all necessary information is included for a successful submission.

Follow the steps to complete the prior authorization request form

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the date the request is being submitted in MM/DD/YYYY format.
3. Provide the name of the office contact person, specifying the individual responsible for the submission.
4. Complete the provider name field with the referring or ordering provider's first and last name.
5. Insert the referring/ordering provider's Medicaid (CMAP) ID.
6. Fill in the NPI (National Provider Identifier) for the physician providing the services.
7. Enter the office phone number of the referring/ordering provider.
8. Include the office fax number of the referring/ordering provider.
9. State the name of the rendering facility or practice where the procedure will take place.
10. Input the address of the rendering facility or practice.
11. Provide the phone number for the rendering facility or practice.
12. Include the fax number for the rendering facility or practice.
13. If available, insert the facility/practice Medicaid (CMAP) ID.
14. Input the member's name for whom the procedure is being requested.
15. Enter the member's date of birth in MM/DD/YYYY format.
16. Fill in the member's Medicaid ID number.
17. Provide the best contact phone number for the member.
18. Select the appropriate program under which the member is covered by checking one box.
19. Describe the procedures being requested in detail.
20. Include the CPT code associated with the requested procedure or procedures.
21. Specify any modifiers relevant to the procedure requested.
22. Indicate the number of units requested for the procedure.
23. Input the clinical indications for the ordered exams, providing supporting medical necessity if applicable.
24. State the primary ICD-10 code for the member.
25. Circle the best days to reach the referring physician from the designated options.
26. Provide the best times to reach the referring physician.
27. Enter the phone number where the referring physician can be contacted.
28. Print and sign the document with the referring provider's name and signature.
29. Once completed, save changes, download, print, or share the form as needed.

Don't delay—complete your prior authorization request online today.