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Request prior authorization

Request prior authorization 2025

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4.8 out of 5

90 votes

The document is a Request for Prior Authorization form used to obtain approval for medically necessary treatments and services. It includes sections for member and provider information, details about the requested service, clinical review requirements, and contact information for various departments. The form emphasizes the need for urgent requests to be processed within 24 hours to prevent serious health deterioration and outlines that authorization does not guarantee payment.

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Click ‘Get Form’ to open the request prior authorization document in the editor.
Begin by entering the 'Date of Request' at the top of the form. Ensure all required fields marked with an asterisk (*) are filled out.
If applicable, check the 'Urgent Request' box to indicate that this is a time-sensitive request requiring attention within 24 hours.
Fill in the 'Member Information' section, including First Name, Last Name, Member ID, and Date of Birth.
Provide 'Servicing Provider Information' by entering NPI, Tax ID, TPI, Contact Number, and Fax Number. Include details for both the servicing provider and referring provider if different.
In the 'Requested Service' section, select the type of service needed and fill in any additional required information such as Place of Service and Procedure Codes.
Complete the 'Clinical Review' section by checking relevant boxes and providing diagnosis codes as necessary.
Finally, ensure you sign in the designated area for the requesting physician before submitting your form for processing.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (90 Votes)
2016	4.3 Satisfied (41 Votes)

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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.

Can I request my own prior authorization?

A pre-authorization is a restriction placed on certain medications, tests, or health services that require your doctor to first check and be granted permission before your plan will cover the item.

How hard is it to get a prior authorization for medication?

Your doctors office is responsible for obtaining prior authorization. They will submit a request to your insurance provider to get approval, whether its for a service or for a medication.

What is a pre authorization request?

Under prior authorization, the provider or supplier submits the prior authorization request and receives the decision before services are rendered.

What is a prior authorization request?

You can submit a request on your own. Find the appropriate prescription drug or medical procedure authorization form for your situation.

Can a patient initiate prior authorization?

Prior authorizations can take time because your prescriber has to submit paperwork and your insurance company needs time to review it. This process can take a few days or even longer especially if your insurer asks for more information or doesnt classify the request as urgent.

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Can you fill out your own prior authorization?

Who is responsible for obtaining prior authorization? The healthcare provider is usually responsible for initiating prior authorization by submitting a request form to a patients insurance provider.