Prior authorization anesthesia 2026

1. Click ‘Get Form’ to open the prior authorization anesthesia form in the editor.
2. Begin with Section I: Patient Information. Fill in the patient's name, date of birth, age, and PEHP ID number accurately.
3. Proceed to Section II: Provider Information. Enter the requested date, service provider NPI number, name, tax ID number, contact person, address, phone, and facsimile details.
4. In Section III: Pre-Authorization Request, specify the requested date of service and check the nature of your request (Auth Extension, Pre-Auth, Retro Auth, Urgent).
5. Complete the facility information including name, place of service (check appropriate option), address, NPI number, phone number, and tax ID.
6. Input primary and secondary medical/treatment diagnosis ICD-10 codes. Then list all requested anesthesia CPT/HCPCS codes along with additional services if applicable.
7. Answer all questions regarding patient conditions and treatment needs by checking relevant boxes and providing comments as necessary.
8. Once completed, review all entries for accuracy before submitting via fax or mail as instructed at the bottom of the form.

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