Get Ma Collaborative - Pet - Pet Ct Prior Authorization Form 2019-2025

This guide provides clear and comprehensive instructions for completing the MA Collaborative - PET - PET CT Prior Authorization Form online. By following the steps outlined, users will effectively fill out all necessary components for the authorization process.

Follow the steps to complete the form accurately and efficiently.

1. Use the ‘Get Form’ button to access and open the MA Collaborative - PET - PET CT Prior Authorization Form.
2. In Section 1, enter the member demographics. Fill in the patient's name (first and last), date of birth (DOB), health plan, member ID number, and group number.
3. Proceed to Section 2 to provide the ordering provider's information. Fill in the physician's name (first and last), primary specialty, NPI, tax ID, phone number, fax number, and contact name.
4. In Section 3, complete the facility information. Enter the facility name, tax ID, full address including city and zip code, phone number, fax number, NPI, and date of service.
5. Move to Section 4 to request the exam. Enter the CPT code(s) and a brief description, followed by the ICD diagnosis code(s) and their descriptions. Include the dates of the first and most recent office visits regarding this condition.
6. Section 5 requires you to complete all applicable information. Indicate the tumor type and date of diagnosis. Select the appropriate radiotracer option(s) that apply.
7. Answer whether the patient has a confirmed cancer diagnosis. Provide details about the patient’s treatment history and select the reason for the study.
8. Indicate the current status of chemotherapy and radiotherapy, including completion dates as necessary. State if there is known cancer spread and if there are suspicions of recurrence.
9. Finally, review all information for accuracy. Ensure to attach any additional data related to medical necessity if needed before submitting the form.

Complete your documents online with confidence using this guide.