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(for Maryland only) Prior Authorization Request Send completed form to: Case Review Unit CVS Earmark Specialty Programs Fax: 18662496155 CVS Earmark administers the prescription benefit plan for the

How to fill out prior authorization request

How to fill out a prior authorization request:

1. Obtain the prior authorization request form from your healthcare provider or insurance company.
2. Fill in your personal information, including your name, date of birth, and contact details.
3. Provide relevant information about the medication or treatment that requires prior authorization, such as the name, dosage, and frequency.
4. Include the diagnosis or medical condition for which the medication or treatment is being prescribed.
5. Attach any necessary supporting documentation, such as medical records or test results, to strengthen your request.
6. Clearly state the reason why you believe the medication or treatment is necessary for your specific medical condition.
7. Sign and date the form, confirming that all the provided information is accurate and complete.
8. Submit the prior authorization request to your healthcare provider or insurance company by the specified method (e.g., mail, fax, online portal).
9. Follow up with your healthcare provider or insurance company if you do not receive a response within the expected timeframe.

Who needs prior authorization request:

1. Patients who are seeking coverage for specific medications or treatments that require prior authorization from their insurance company.
2. Healthcare providers who want to ensure that their prescribed medications or treatments will be covered and reimbursed by the patient's insurance plan.
3. Insurance companies that require prior authorization to verify the medical necessity and appropriateness of certain medications or treatments before approving coverage and reimbursement.

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What is prior authorization request?

Prior authorization request is a process by which healthcare providers must obtain approval from a health insurance plan before a specific service is provided to the patient.

Who is required to file prior authorization request?

Healthcare providers such as doctors, hospitals, and pharmacies are required to file prior authorization requests.

How to fill out prior authorization request?

Healthcare providers must complete a form provided by the insurance company with all necessary information about the patient and the requested service.

What is the purpose of prior authorization request?

The purpose of prior authorization request is to ensure that the requested service is medically necessary and meets the guidelines of the insurance plan.

What information must be reported on prior authorization request?

Information such as patient demographics, diagnosis, treatment plan, and justification for the requested service must be reported on the prior authorization request.