Medicare - Virginia Premier 2026

1. Click ‘Get Form’ to open the Medicare - Virginia Premier document in the editor.
2. Begin by entering the member information. Fill in the Member Name, DOB, and Member ID. If applicable, provide the enrollment date for retroactive enrollments.
3. Next, complete the provider information section. Include details such as Provider Group/Clinic, Clinical Contact, Street Address, City, State, Zip, Provider ID/NPI, Phone, and Fax.
4. In the ICD-10 Diagnosis Code section, enter all relevant diagnosis codes. Ensure you include primary and any co-occurring codes.
5. For Service Authorization, input the existing service authorization number and requested end date for the extension.
6. Specify the ASAM Level of Care requested along with the number of units required for each code description listed.
7. Document medications prescribed by listing their names along with type/dosage/frequency and patient response.
8. Complete assessment dimensions by providing summaries for each dimension based on clinical needs and attach any necessary documentation.
9. Finally, ensure to sign off on the form by entering your name and credentials before submitting it to the designated health plan using provided contact information.

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