Get Pre-authorization Request Form - Altrua Healthshare

Completing the Pre-authorization Request Form for Altrua HealthShare is a vital step in ensuring that your healthcare needs are met. This guide provides clear instructions to help you navigate each section of the form effectively.

Follow the steps to complete your online pre-authorization request.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Start by filling in the 'To' field with 'Eligibility Dept'. This indicates the department that will handle your request.
3. Enter the number of pages to be submitted, including the cover sheet, in the designated section.
4. Provide the fax number (737-402-7752) where the request will be sent. This is crucial for timely processing.
5. Indicate the type of review you are requesting by selecting either 'Urgent' or 'Non-urgent'. If the request is urgent, briefly describe the clinical reason for urgency.
6. Fill in your contact details, including the treating physician's information. This should include the physician's name, fax number, and phone number.
7. Enter the name and phone number of the facility where the services will be provided. This assists in streamlining communication.
8. Provide the 'Date of Request', which is the date you are submitting this form.
9. Fill in the anticipated date of service (DOS) when the procedure is expected to take place.
10. Fill in the member's name, ID, and date of birth. This identifies the individual for whom you are requesting pre-authorization.
11. List the requested CPT codes for the procedures you are seeking authorization for, ensuring accuracy to avoid delays.
12. Include associated ICD-10 codes relevant to the diagnosis. This is necessary for the approval process.
13. Add any additional comments or relevant information in the comments section to assist the reviewing team.
14. Review all the entered information for accuracy. Ensure that only dictated or typed documentation is provided, as handwritten notes will not be accepted.
15. Once your form is complete, you can save changes, download, print, or share the form as needed.

Submit your pre-authorization request online today to ensure your healthcare needs are addressed promptly.