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Pre service review request for authorization form 2026

The document is a Pre-Service Review Request for Authorization Form, designed for services requiring prior elevated nurse or medical review. It outlines the necessary steps for completing the form, including attaching clinical documentation to support medical necessity, and specifies different fax numbers for various types of services. The document emphasizes the importance of providing complete information to avoid delays in processing requests and includes instructions for checking authorization status and contacting provider services.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the Provider Information section. Enter the provider’s name, date, phone number, fax number, tax ID, and office contact’s name along with their phone number.
Next, provide details about the Member/Patient Information. Fill in the member's name, member number, and date of birth.
In the Treatment Information section, specify the dates of service or admit date. Indicate the place of service by checking one of the options: Inpatient, Outpatient, Office, or Patient’s Home.
List the diagnosis and procedure codes accurately. If applicable, include information regarding clinical trials and attach necessary documentation.
Finally, ensure all fields are completed and attach any required clinical documentation before submitting your request.

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