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Healthsmart prior authorization request form

Healthsmart prior authorization request form 2026

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The document outlines the Prior Approval Request Form for the West Virginia Public Employees Insurance Agency's Pharmacy Prior Approval Program. It includes sections for patient and medication information, prescriber details, and pharmacy information, along with questions regarding previous treatments and therapeutic reasons for medication requests. The document emphasizes confidentiality and provides contact information for assistance.

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Click ‘Get Form’ to open the healthsmart prior authorization request form in the editor.
Begin by filling out the 'Patient and Medication Information' section. Enter the patient's name, PEIA identification number, date of birth, requested medication name, dosage, directions for use, and primary diagnosis. If applicable, include any secondary diagnoses.
Next, complete the 'Prescriber Information' section. Input the prescribing practitioner's name, address, DEA number, specialty, and contact information.
If known, provide details in the 'Pharmacy Information' section including the dispensing pharmacy's NABP number and address.
Answer all questions in Section IV regarding previous treatments and therapeutic reasons for medication requests. Be sure to provide detailed responses as needed.
Finally, ensure that the prescriber signs the form. If using a signature stamp, remember to initial it as required.

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2011	4 Satisfied (34 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.

What type of insurance is HealthSmart?

HealthSmart insurance offers coverage for a range of healthcare services, including mental health and substance misuse treatment.

What is a prior authorization intake form?

Prior authorization requires your doctor or provider to obtain approval from your health plan before providing health care services or prescribing prescription drugs. Without prior authorization, your health plan may not pay for your treatment or medication. (Emergency care doesnt need prior authorization.)

Who is responsible for obtaining preauthorization?

Studies show the average cost for prior authorization approval on primary care practices ranged from $2,161 to $3,430 annually per full-time physician. In addition to the impact on physicians, prior authorization requirements have been found to harm patient care.

How to obtain prior authorization?

How To Get Prior Authorization: Step-by-Step Guide Step 1: Check client eligibility. Step 2: Determine if a code or service requires Prior Authorization. Step 3: Find and complete forms. Step 4: Submit a PA request. Step 5: Check the status of an authorization.

What is the phone number for HealthSmart prior authorization?

The Guide is available at healthsmart.com/nysut or by calling HealthSmart toll-free at 844-552-7805.

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