Get Pehp Health & Benefits Prior Authorization For Anesthesia Services For Dental Procedures Under 2022-2025

Filling out the PEHP Health & Benefits Prior Authorization for Anesthesia Services for Dental Procedures does not have to be a daunting task. This guide provides clear step-by-step instructions to help ensure all necessary information is accurately captured for the authorization process.

Follow the steps to complete the prior authorization form accurately.

1. Click ‘Get Form’ button to access the documentation required for authorization and open the form in your preferred editing tool.
2. Begin with Section I: Patient Information. Enter the patient's name in the format 'Last, First MI', along with their date of birth (DOB), age, and PEHP ID number.
3. Proceed to Section II: Provider Information. Fill in the requested date, the ordering provider's name and contact person, and their National Provider Identifier (NPI) number, phone, and fax details. Also include the rendering provider's information, including their NPI, tax ID number, address, and contact details.
4. Move to Section III: Pre-Authorization Request. Check the appropriate box indicating the nature of the request (e.g., pre-authorization) and enter the primary diagnosis ICD-10 code along with any secondary diagnosis codes.
5. Complete the 'Requested Date(s) of Service' section by specifying the date range for the requested services and select the type of anesthesia being requested from the provided options.
6. Specify the place of service and type of service requested, along with the estimated anesthesia time. You must also list all requested procedures and their corresponding CPT or HCPCS codes.
7. Continue with the checklist of medical conditions and comments to determine specific circumstances surrounding the patient that might necessitate anesthesia services.
8. Lastly, review all entries for accuracy, then save changes to the completed form. You can download, print, or share the document as needed for submission.

Complete your authorization forms online today for a smoother process.