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Pre treatment authorization

Cut0124 1e 2026

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4.8 out of 5

225 votes

The document outlines the procedures for outpatient pre-treatment authorization requests (OPAP) for various therapies, including physical therapy, occupational therapy, and chiropractic services. It provides instructions for participating providers on how to initiate requests, check status, and submit claims. The form requires patient information, diagnosis codes, and treatment details. Additionally, it includes guidelines for verifying eligibility and benefits, as well as a disclaimer regarding authorization based on medical necessity. The document also emphasizes non-discrimination policies and offers language assistance services.

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Click ‘Get Form’ to open the cut0124 1e in the editor.
Begin by filling out the 'Patient Name' section with the last and first name of the patient. Ensure accuracy as this is crucial for identification.
Enter the 'Date of Birth' in the specified format (mm/dd/yyyy). This helps in verifying patient eligibility.
In the 'Diagnosis Code(s)' field, input the relevant ICD-10 codes that correspond to the patient's condition.
Complete the 'Subscriber Member ID#' and select the patient's gender by checking either 'Male' or 'Female'.
Indicate the 'Number of Visits' required and specify the date range for services under 'From' and 'To'.
Fill in details for the servicing practitioner, including their name, BlueChoice Regional Provider ID #, and contact information.
If applicable, complete any sections regarding authorization extensions or additional comments before submitting.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (225 Votes)
2016	4.1 Satisfied (70 Votes)
2010	4 Satisfied (49 Votes)

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