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Get Optumrx Er Prior Authorization Request Form 2015
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How to fill out the OptumRx ER Prior Authorization Request Form online
Filling out the OptumRx ER Prior Authorization Request Form is a crucial step in ensuring that patients receive the necessary medication in a timely manner. This guide provides a step-by-step walkthrough to help users complete the form accurately and efficiently.
Follow the steps to successfully submit your request
- Click ‘Get Form’ button to access the OptumRx ER Prior Authorization Request Form and open it for editing.
- Begin by filling out the member information. Enter the member's name, date of birth, and insurance ID number in the designated fields. Provide details such as the member's contact information and address.
- Next, complete the provider information section. Input the provider's name, NPI number, office phone, fax, address, and specialty.
- In the medication information section, indicate the medication name and strength. Check the box if you are requesting the brand version, and specify if this request is for the continuation of therapy.
- Provide the directions for use and dosage form as required.
- Select the relevant diagnosis and provide the corresponding ICD-9/10 codes. If other diagnoses apply, fill in the necessary details.
- List any medications the patient has previously failed, had contraindications to, or experienced intolerances with. Include brand if it applies.
- Indicate the quantity limit requested per day and confirm whether the diagnosis includes malignant pain. Also, specify if a pain specialist prescribed the medication.
- Document whether chart notes confirming treatment details will be submitted. Ensure that all required documentation aligns with the requirements outlined.
- In the comments section, provide any additional information that may support the prior authorization request.
- Once you have completed all sections of the form, review your entries for accuracy. Save your changes, and choose to download, print, or share the form as needed.
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The typical processing time for an Optum Rx prior authorization is usually within 5 to 7 business days. However, this can vary depending on the complexity of your case and the completeness of your OptumRx ER Prior Authorization Request Form. You can check the status of your authorization through the Optum Rx portal for updates.
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