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Prior Authorization Request Form - InterCommunity Health Network

Prior Authorization Request Form - InterCommunity Health Network 2025

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The document outlines the process for filing a third-party liability claim with Samaritan Health Plans following an accident that may involve another party's responsibility or insurance coverage. It provides instructions for members to report details about the incident, including types of accidents (motor vehicle, work-related, etc.), and requires specific information to facilitate claims processing. Additionally, it includes a notice of subrogation provision, explaining the plan's right to reimbursement for benefits paid due to injuries caused by another party.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is a prior authorization request form?

Prior authorization (prior auth, or PA) is a management process used by insurance companies to determine if a prescribed product or service will be covered. This means if the product or service will be paid for in full or in part.

Is it difficult to get prior authorization?

Prior authorization is a time-consuming, labor-intensive, and often frustrating process. Requests require several steps, and theres often a lot of back and forth with payers, especially if the initial request isnt accurate and complete.

Who is responsible for obtaining preauthorization?

Your health care provider can make the prior authorization request. If your provider submits the request, they will send the required information to your health plan. You may need to fill out forms for your providers office.

How to get prior authorization for insurance?

What are the steps to obtaining prior authorization? Your insurance company will review your doctors request. Once theyve decided, theyll send their decision to both you and your medical provider in writing. If your doctor feels that you cant wait that long, they can submit an urgent or expediated request.

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