Get the free IMO Pre-Authorization NON-NETWORK Request Form

INJURY MANAGEMENT ORGANIZATION, INC. PreAuthorization Request Form (Network) Tel: 9723878297 or 8777424477 Fax: 9729915572 or 8882759946 Submit Request Online: www.injurymanagement.com CLAIM PROFILE

How to fill out imo pre-authorization non-network request

How to fill out imo pre-authorization non-network request?

1. Start by gathering all the necessary information. You will need the patient's personal details, including their name, date of birth, address, and contact information. Additionally, have the insurance details available, such as the policy number and group number.
2. Identify the healthcare service or procedure for which the imo pre-authorization non-network request is being made. Provide a detailed description of the service, including any relevant medical codes or terminology.
3. Indicate the specific dates or duration for which the pre-authorization is required. If the service has already been performed, mention the date of the procedure.
4. Explain why the requested service is necessary for the patient's health and well-being. Include any supporting documentation, such as medical records, test results, or letters from healthcare professionals.
5. Provide information about the healthcare provider who will be performing the service. Include the provider's name, address, and contact details. If applicable, mention their specialty or qualifications.
6. Clearly state the expected costs associated with the requested service. This should include any estimated fees for the procedure, as well as any additional expenses such as medications or follow-up appointments.

Who needs imo pre-authorization non-network request?

1. Patients who are seeking healthcare services from a provider that is not included in their insurance company's network may need to submit an imo pre-authorization non-network request.
2. This request ensures that the insurance company is aware of the planned non-network service and can determine if it is medically necessary and covered under the policy.
3. It is important to note that not all insurance plans require pre-authorization for non-network services. However, it is always advisable to check with the insurance provider to determine their specific requirements.

Overall, filling out an imo pre-authorization non-network request involves providing detailed information about the requested service and the patient's medical circumstances. This allows the insurance company to evaluate the necessity of the service and determine coverage accordingly.

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