PRIOR AUTHORIZATION for ANESTHESIA SERVICES for DENTAL - Fill ... - signNow 2025

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by filling out Section I: PATIENT INFORMATION. Enter the patient's name, date of birth, age, and PEHP ID number.
  3. Proceed to Section II: PROVIDER INFORMATION. Input the date requested, ordering provider's details including contact person, NPI number, and phone/fax numbers.
  4. In Section III: PRE-AUTHORIZATION REQUEST, check the nature of your request (e.g., Pre-Authorization) and provide primary and secondary diagnosis codes.
  5. Select the type of anesthesia requested and place of service. Ensure you list all requested procedures along with their corresponding CPT/HCPCS codes.
  6. Answer the questions regarding patient conditions that may affect anesthesia services. Provide any additional comments as necessary.
  7. Once completed, review all sections for accuracy before saving your document. You can then fax or mail it as instructed.

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Although anesthesia itself is not typically the direct target of prior authorization, the services it supports, such as imaging, surgery, and certain pain management interventions, frequently are.
Drugs That May Require Prior Authorization Drug ClassDrugs in Class Epidiolex Epidiolex Erythroid Stimulants , , Procrit and Retacrit, Mircera Esbriet Esbriet Evenity Evenity243 more rows
Anesthesia itself does not require prior authorization; however, prior authorization may be required for the related surgical procedure or service.
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Prior authorization is a way for insurance companies to review the medical service, procedure, item, or medication requested and make sure that its necessary for your care. Examples of services or procedures for which prior authorization may be needed include: admission to a hospital or skilled nursing facility.
A helpful mnemonic is that, in addition to confirming that the patient is fit for surgery, the anaesthesia team should complete the ABCDEs an examination of the Airway equipment, Breathing system (including oxygen and inhalational agents), suCtion, Drugs and Devices and Emergency medications, equipment and assistance

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