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OSU Health Plan Genetic Testing Prior Authorization Form
Email completed form with required documentation to: UtilizationManagement.OSUHealthPlan@osumc.edu Or fax to: 614-292-2667. MEMBER INFORMATION. ORDERING
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GENETIC TESTING SERVICE AUTHORIZATION REQUEST
The following provider information is required to complete the service authorization request: Procedure Request. Billing Provider Name and NPI - name of the
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Outpatient Medicaid Authorization Form
Complete and Fax to: 866-796-0526. Transplant Request Fax to: 833-550-1338. DME 205 Genetic Testing Counseling. 249 Home Health. 225 Home Meals. 390 Hospice
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