PRIOR AUTHORIZATION for ANESTHESIA SERVICES 2026

1. Click ‘Get Form’ to open it 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 date requested, ordering provider's details including contact person, NPI number, and phone/fax numbers.
4. In Section III: PRE-AUTHORIZATION REQUEST, specify the requested dates of service and select the nature of request (e.g., Pre-Authorization).
5. Indicate the primary diagnosis using ICD-10 codes and select the type of anesthesia requested from the provided options.
6. Complete additional fields regarding place of service, estimated anesthesia time, and list all requested procedures with corresponding CPT/HCPCS codes.
7. Finally, review your entries for accuracy before submitting. Ensure all necessary patient chart notes are included.

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