Get Pre Rauthorization Request Form - Injurymanagementcom

Filling out the PRE RAUTHORIZATION REQUEST FORM is an essential step in initiating the approval process for necessary medical treatments. This guide will walk you through each section of the form to ensure you provide the necessary information accurately and completely.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the form and open it in your editing tool.
2. Indicate whether the employee is a participant in the Certified Network by selecting 'Yes' or 'No'.
3. For the URA request, ensure that the requesting medical provider includes appropriate clinical notes along with the submitted treatment request.
4. Fill in the patient information section, including the patient’s name, date of birth (D.O.B.), date of injury (D.O.I.), and social security number (S.S.N.).
5. Complete the provider information section by entering the requesting physician's name, specialty, address, phone number, and email address for receiving determination letters.
6. Provide the insurance and claim information, including the employer's name, insurance company, adjuster’s name, and claim number.
7. In the facility information section, note the name, address, phone number, and email address of the place of service, along with relevant details such as tax ID number and contact person.
8. Specify the dates of service, the type of service (inpatient or outpatient), and the requested procedure.
9. Include the ICD-9 codes and CPT codes that pertain to the requested services.
10. Attach all necessary supporting medical documentation, including testing reports and medical notes, to validate the medical necessity of the requested services.
11. Once all sections are completed, review your information for accuracy, save changes, and you may opt to download, print, or share the completed form.

Begin filling out your PRE RAUTHORIZATION REQUEST FORM online today to ensure timely processing of your medical request.