Get Caresource Indiana Prior Authorization Form

Completing the Caresource Indiana Prior Authorization Form online is an essential step in ensuring that your requests for medical services are processed efficiently. This guide provides a comprehensive walkthrough of each section of the form to help users navigate the process with ease.

Follow the steps to successfully complete your prior authorization request.

1. Click ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by filling out the patient information section. Indicate whether the request is routine or urgent and provide the date of request, member ID number, last name, first name, address, date of birth, and phone number.
3. Attach clinical notes that include the patient's history and prior treatment. Specify whether the request is for inpatient or outpatient services.
4. Enter the ordering provider's information, including name, tax ID number, NPI number, phone, fax, and address.
5. Fill in the requested date of service and the facility or service provider's details, including their name, address, phone, fax, tax ID, NPI, diagnosis codes (ICD-9), and description.
6. Provide additional information as necessary, detailing the requested procedures, services, or surgeries, along with the procedure codes (CPT/HCPCS) and the quantity.
7. For durable medical equipment, orthotics, prosthetics, or vision items, include make and model, charge amounts, as well as the number of visits required.
8. If applicable, indicate whether any other liability exists, such as work, auto, or other insurance details.
9. Complete the form with your information, indicating who completed the form.
10. Review the form for accuracy, then save your changes, and proceed to download, print, or share the completed form as needed.

Complete your Caresource Indiana Prior Authorization Form online today for efficient processing of your requests.