Get Ct Husky Health Advanced Imaging Prior Authorization Request Form 2016-2026

Completing the CT Husky Health Advanced Imaging Prior Authorization Request Form online can enhance efficiency and streamline the authorization process. This guide provides clear, step-by-step instructions for filling out each section of the form to ensure that all necessary information is accurately submitted.

Follow the steps to fill out the form successfully.

1. Press the ‘Get Form’ button to obtain the form and open it in an editing interface.
2. Fill in the date request submitted. Enter the date using the format MM/DD/YYYY.
3. Provide the name of the office contact person, ensuring the person is available for any follow-up.
4. Enter the referring provider's full name, including both first and last names.
5. Insert the referring provider's Medicaid (CMAP) ID number, which is mandatory.
6. Provide the physician's Medicaid ID and their NPI (National Provider Identifier) number.
7. Input the referring provider's office phone number in the format (XXX) XXX-XXXX.
8. Include the referring provider's office fax number in the same format.
9. Enter the name of the facility or practice where the procedure will take place.
10. Fill in the facility or practice's address, including the street, city, state, and ZIP code.
11. Provide the facility's phone number, formatted as (XXX) XXX-XXXX.
12. If available, insert the facility's Medicaid (CMAP) ID number.
13. Input the member's name for whom the procedure is being requested.
14. Provide the member's date of birth in the format MM/DD/YYYY.
15. Enter the member's Medicaid ID number.
16. Provide the best contact phone number for the member in the format (XXX) XXX-XXXX.
17. Select the appropriate program by checking the corresponding box (A, B, C, D, or Limited Benefits Group).
18. List the description or modality of the procedure(s) being requested.
19. Input the corresponding CPT code for the requested procedure(s).
20. If necessary, list any modifiers related to the procedure, such as left or right side.
21. Specify the number of requested units for the procedure.
22. Detail the clinical indications for the ordered exams, including relevant medical history if applicable.
23. Provide the primary ICD-10 code, ensuring that at least one diagnosis accompanies each CPT code.
24. Check the best days of the week to reach the referring physician.
25. Indicate the preferred times of day to contact the referring physician.
26. Input the best phone number for reaching the referring physician.
27. Clearly print the name of the referring or ordering provider.
28. The referring provider must sign the form to confirm the request.

Complete your authorization request online today to save time and ensure accuracy.