Get Wellsense Health Plan Medical Prior Authorization Request Form 2021-2025

Filling out the WellSense Health Plan Medical Prior Authorization Request Form online can be a straightforward process if you follow the right steps. This guide provides detailed instructions to help users of all levels complete the form accurately and efficiently.

Follow the steps to complete your authorization request online.

1. Click 'Get Form' button to obtain the form and open it in your preferred editor.
2. Begin with the member information section. Enter the member's name, date of birth (DOB), WellSense ID number, phone number, and fax number. Ensure accuracy to avoid potential processing delays.
3. Proceed to the submitted by/sender information section. Fill in your name and direct line as the person submitting the request.
4. In the provider information section, include the requesting provider's name, National Provider Identifier (NPI) number, and select if they are a primary care provider (PCP) or a specialist. Also, fill in the servicing provider details and facility information, ensuring to include their NPI number.
5. Next, move to the requested services section. Check the appropriate services being requested, such as office visit/consult, surgery, or outpatient rehab. If applicable, provide additional details such as the expected number of visits and the specific dates for therapy services.
6. For each service requested, be precise in filling out the diagnosis codes and CPT codes. Ensure these codes reflect the services being rendered to avoid any discrepancies.
7. If you require DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) or oral enterals, ensure to contact Northwood directly for authorization and follow their specific procedures.
8. Review your entries thoroughly. Confirm all sections are complete and accurate to prevent delays in processing your request.
9. Finally, save your changes, then download, print, or share the form as necessary to submit your authorization request.

Complete your WellSense Health Plan Medical Prior Authorization Request Form online today for a smoother submission process.