Get 047 Preauthorization Request Form For Surgical Management Of Obesity

The 047 Preauthorization Request Form For Surgical Management Of Obesity is an essential document for individuals seeking coverage for gastric bypass surgery. This guide provides a detailed, step-by-step approach to accurately completing the form online, ensuring compliance with the medical necessity criteria set by Blue Cross Blue Shield of Massachusetts.

Follow the steps to accurately complete your preauthorization request form.

1. Click the ‘Get Form’ button to access the 047 Preauthorization Request Form For Surgical Management Of Obesity. This will allow you to open the form in an editable format.
2. Begin by filling out the patient information section. Enter the patient's name, today’s date, Blue Cross Blue Shield ID number, date of surgery, date of birth, height and weight, blood pressure, and current BMI.
3. Next, provide the physician information. Include the physician’s name and facility details, including the address, phone number, and fax number. Ensure to list the National Provider Identifier (NPI) numbers as well.
4. Proceed to the procedure information section. Select the appropriate diagnosis codes that apply to the patient's condition, ensuring to check the correct boxes next to each relevant diagnosis code related to morbid obesity.
5. Specify the procedure codes relevant to the surgery. Carefully choose the procedure that aligns with the planned surgical intervention by marking the appropriate box next to the corresponding code.
6. Detail any other diagnoses or co-morbid conditions present in the patient’s medical record, using the indicated space provided. This information is crucial for establishing medical necessity.
7. Indicate the patient selection criteria by checking the boxes next to any co-morbidities that apply to the patient. This section helps to demonstrate the urgency and need for the surgical intervention.
8. Finally, confirm that the physician has provided sufficient information regarding the patient’s motivation and preparedness for the surgery by marking the relevant checkboxes.
9. Once all sections of the form are completed, you can review the information for accuracy. Save your changes, download the form for your records, and print copies as needed for submission.
10. Submit the completed form via fax to 1-888-282-0780 as instructed. Ensure to keep a copy of the form for your records.

Take the next step towards your health by filling out the 047 Preauthorization Request Form For Surgical Management Of Obesity online today.