Get Ut Prior Authorization Request Form 2019

Filling out the UT Prior Authorization Request Form online is a critical process for obtaining approvals for physical and occupational therapy services. This guide will walk you through each section of the form, ensuring you provide the necessary information accurately and efficiently.

Follow the steps to complete your request effectively.

1. Press the 'Get Form' button to access the UT Prior Authorization Request Form and open it for editing.
2. Fill in the 'Date of submission' field with the current date to document when the request is made.
3. Indicate if this request is retroactive by selecting 'Yes' or 'No.' If 'Yes,' provide a reason in the 'additional information' section.
4. Specify whether this request represents a change to a previous prior authorization by selecting 'Yes' or 'No.' If it is a change, enter the previous PA number.
5. Select the type of therapy requested: Physical Therapy, Occupational Therapy, or Both.
6. Enter the 'Requested dates of service' by filling in the start and end dates for when services are needed.
7. Indicate the 'Requested number of visits.' Remember that each date of service counts as one visit, regardless of the number of modalities provided.
8. Choose the Medicaid Program coverage: Traditional or Non-Traditional, ensuring you understand the conditions of each type.
9. Confirm if physical therapy limitations have been met by selecting 'Yes' or 'No.' This is important for requests exceeding allowable limits.
10. Also confirm if occupational therapy limitations have been met by selecting 'Yes' or 'No.'
11. Complete the Member Information section by filling in the member's name, ID number, date of birth, age, and gender.
12. In the Provider Information section, enter the provider's name, NPI number, address, phone number, and fax number.
13. Include the name of the office contact person to ensure effective communication.
14. Review all entered information for accuracy and completeness before submitting the form.
15. Once all information is filled out, you can then save changes, download, print, or share the completed form as needed.

Complete your UT Prior Authorization Request Form online today to ensure timely processing of your request.