Follow the steps to complete the Universal Precertification Request Form.

1. Press the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering today’s date in the designated field. This helps in tracking the request time frame.
3. Fill out the provider return fax number where you wish to receive the confirmation of the request.
4. In the 'Member Information' section, provide the member's first name, last name, Healthy Blue ID, date of birth, contact phone, and address, including city, state, and ZIP code.
5. Proceed to complete the 'Referring Provider' details. Indicate if the provider is participating or nonparticipating. Fill in their full name, specialty, NPI, TIN, provider ID, office contact name, office phone, and fax, along with their address.
6. Next, provide the 'Servicing Provider' information in the same manner as the referring provider.
7. Enter the details of the 'Servicing Facility,' specifying if the facility is participating or nonparticipating. Include all necessary contact details.
8. Input the 'Requested Service' section with the date or date range of service, ICD-10 codes, CPT codes and units requested, and select the type of service that applies.
9. Specify the place of service from the provided options such as hospital or office.
10. Complete any additional information required for your request, including service categorization.
11. If this is related to an existing authorization, enter the authorization number.
12. Review the form for completion and accuracy.
13. Save your changes, then download, print, or share the form as needed to finalize your submission.

Take action now and complete your Universal Precertification Request Form online for faster processing.