Get Ucare Injectable Drug Prior Authorization Request Form 2020-2025

Filling out the UCare Injectable Drug Prior Authorization Request Form online can streamline the authorization process for non-contracted providers. This guide offers a clear, step-by-step approach to help users navigate each section of the form effectively.

Follow the steps to complete the form online efficiently.

1. Press the ‘Get Form’ button to retrieve the form and open it in your editing interface.
2. Begin by entering the request date at the top of the form.
3. In the Member Information section, provide the member's name, date of birth, and UCare member ID. If applicable, include the PMI and the member's address, city, state, and ZIP code. Lastly, enter the best contact number.
4. Move to the Prescriber/Ordering Clinic Information section. Fill in the name of the requesting clinic, point of contact name, and their phone and fax numbers. Include the ordering prescriber’s name, NPI, specialty, and phone number.
5. Indicate the location for the drug administration by providing the name of the clinic or facility, along with its address, phone, and fax numbers. Include the NPI for the facility administering the drug.
6. If the billing provider information is different from the drug administration location, complete the billing provider section with their NPI and address details.
7. Enter the drug requested and the number of units required in the designated fields.
8. Provide the necessary drug information including the HCPCS procedure code, NDC number, member height, weight, and expected duration of therapy. Fill in the authorization start date.
9. Answer whether the member is currently being treated with the requested drug and provide the start date if applicable.
10. Indicate if the prescriber attests that the patient has had a response to treatment.
11. Complete the diagnosis related to the drug request and provide the corresponding ICD-10 code(s). If there are additional medications to be used in combination, list them.
12. Lastly, document any previous therapies that have been tried.
13. Once all sections are complete, review the form for accuracy, then save your changes, and download or print the completed document. You may also share it as needed.

Complete your UCare Injectable Drug Prior Authorization Request Form online today!