Get Ny Centerlight Healthcare Request Form For Prior Authorizations 2015-2025

Navigating the NY CenterLight Healthcare Request Form for Prior Authorizations can be straightforward with the right guidance. This step-by-step guide will support you in accurately completing the form online, ensuring you provide all necessary information for your authorization request.

Follow the steps to effectively complete the authorization request form.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Indicate the date of your request to maintain a record of when the authorization was submitted.
3. Select whether your request is standard or expedited by checking the appropriate box.
4. Provide your name and contact number in the 'Request Sent By' section to ensure the proper communication.
5. Fill in the member's name accurately, using their first and last names.
6. Select the area where the patient resides by checking one of the listed boxes.
7. Enter the member's ID number to link the request to their specific health plan.
8. Choose the plan type by checking the applicable boxes: Direct, PACE, Select, or FIDA.
9. Input the referring provider's name, ensuring you specify if they are a primary care provider or specialist.
10. Provide the name of the provider you are referring to, along with their type (in-network or out of network).
11. Include the contact number for the referred provider's office to facilitate follow-up.
12. Clearly state the reason for your request, providing as much detail as possible, and attach any necessary clinical information.
13. Specify the type of service requested to ensure clarity in your authorization needs.
14. Note the dates of service or the number of visits being requested.
15. Indicate the place of service, which could be a hospital, clinic, or another facility.
16. Fill in the diagnosis or applicable ICD9 code to support the medical necessity of your request.
17. Provide the procedure or CPT code related to the service being requested.
18. If applicable, explain the reason for requesting out-of-network services.
19. Include the out-of-network provider's address, tax ID, and NPI for record-keeping.
20. After completing all sections, review your information for accuracy. Users can then save changes, download, print, or share the completed form.

Start filling out the NY CenterLight Healthcare Request Form for Prior Authorizations online today to ensure timely processing of your request.