Get Alignment Health Prior Authorization Request 2024-2025

Completing the Alignment Health Prior Authorization Request is essential for obtaining necessary health services. This guide provides clear instructions on filling out the form to ensure a smooth submission process.

Follow the steps to successfully complete your request.

1. Click ‘Get Form’ button to access the Alignment Health Prior Authorization Request form and open it in your preferred document editor.
2. Fill in the priority section by selecting either 'Routine' or 'Urgent.' Remember that 'Urgent' indicates a situation where delays could seriously jeopardize the health or function of the member.
3. Enter the Health Plan Member ID number in the designated field. This information is crucial for processing your request.
4. Provide the date of the request and the patient's name clearly. Ensure to include the last name, first name, and middle name if applicable.
5. Complete the patient's address, including city, state, and zip code to facilitate accurate communication.
6. In the 'Type of Service' section, check all applicable options, including hospital services, outpatient services, office visits, durable medical equipment, or home health.
7. Specify the physician or facility the patient is referred to, including their address and phone number.
8. Document the patient's sex and date of birth, which helps identify and associate the records accurately.
9. Indicate the diagnosis along with the corresponding ICD-10 codes for clarity and efficient review.
10. Describe the procedure with any applicable CPT codes. Make sure to indicate the number of units or quantity required.
11. If applicable, include any injectable drugs with their NDC numbers and quantities.
12. Utilize the additional codes section for any extra NDC and units, ensuring all relevant information is captured.
13. Attach any pertinent progress notes or diagnostic studies that will support and validate your request.
14. Complete the requesting physician's information and provide telephone numbers for both the person completing the form and the requesting physician.
15. After ensuring that all fields are filled out correctly, save changes, and choose to download, print, or share the completed form.

Start filling out your Alignment Health Prior Authorization Request online today for timely health service approvals.