Get the free 2012 Prior Authorization Fax Form - Coventry Medicare ...

(and) PRIOR AUTHORIZATION FORM Coverage Criteria: Covered for patients with treatment resistant major depressive disorder that have failed to respond to at least 2 separate previous trials of antidepressants

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What is prior authorization fax form?

Prior authorization fax form is a document that healthcare providers use to request approval from insurance companies before providing certain medical services or prescribing certain medications.

Who is required to file prior authorization fax form?

Healthcare providers or their designated staff are required to file the prior authorization fax form.

How to fill out prior authorization fax form?

To fill out the prior authorization fax form, healthcare providers need to provide patient information, details about the requested service or medication, medical necessity documentation, and any supporting documents requested by the insurance company.

What is the purpose of prior authorization fax form?

The purpose of the prior authorization fax form is to obtain approval from the insurance company before providing or prescribing specific medical services or medications, ensuring coverage and reimbursement.

What information must be reported on prior authorization fax form?

The prior authorization fax form typically requires information such as patient demographics, insurance information, provider information, CPT or HCPCS codes, diagnosis codes, medical necessity documentation, and any other supporting documents requested by the insurance company.

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