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How to use or fill out CUT0124 Outpatient Pre-Treatment Authorization Program OPAP Initial Request
- Click ‘Get Form’ to open it in the editor.
- Begin with Part I: Patient Information. Fill in the patient's name, date of birth, and subscriber's information including Member ID and address. Ensure all fields are completed legibly.
- Move to Part II: Request for Authorization. Enter the practitioner's name, agency details, and contact information. Specify the medical diagnosis using ICD-9-CM codes and indicate if the condition is related to employment or an accident.
- Complete the number of visits requested and the dates of service. Make sure these align with your claims to avoid processing delays.
- Review Part III: Disclaimer for any additional requirements regarding authorization and eligibility verification before submitting.
- Finally, fax the completed form to 410-505-6404 within five days of evaluation to ensure timely processing.
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