Get Utilization Review For Prior Authorization / Medical Exception Form

Filling out the Utilization Review For Prior Authorization / Medical Exception Form online can streamline the process of obtaining necessary medical services. This guide provides a clear, step-by-step approach to completing the form to ensure all required information is included for efficient processing.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient information. Fill in the last name, first name, member ID number, and date of birth in the designated fields.
3. Next, specify the service date(s) or service period related to the request. Ensure this information is accurate and clearly stated.
4. List the patient diagnosis or diagnoses along with the corresponding ICD-10 codes. This information is crucial for the review process.
5. Provide details for the ordering or referring provider. Fill in the name, address, NPI number, tax ID number, phone number, fax number, and the name and extension of the nurse contact.
6. If applicable, include the servicing provider's information in the same manner as for the ordering provider, ensuring all required details are provided.
7. If there is a servicing facility or vendor involved, complete that section accurately, including their name, address, NPI number, tax ID number, and contact information.
8. Detail the requesting service, including any relevant CPT or HCPCS codes for procedures, equipment, or materials. Clearly describe what is being requested.
9. Provide a brief patient-specific rationale for the request, ensuring to include any necessary background and justification for the service being requested.
10. Remember to attach all supporting clinical documentation required for the request. This may include reports from consultations, office visits, lab results, and radiology findings.
11. Complete the contact information for the person submitting the request, including their name, phone number, extension, address, and fax number.
12. Finally, review all entered information for accuracy. Once confirmed, save changes, download, print, or share the form as needed.

Complete your documents online to ensure efficient processing.