Get the free Out-of-Network Referral Form - UHCRiverValley.com

OUT OF NETWORK PRIOR AUTHORIZATION REQUEST FAX: 800-299-3779 PROTECTED Phone: 800-747-1446 INFORMATION TO BE COMPLETED BY REFERRING PHYSICIAN OFFICE Please PRINT Date submitted: Are the Services Requested

How to fill out out-of-network referral form

How to fill out out-of-network referral form:

1. Start by gathering all necessary information: This includes your personal details, such as your name, address, phone number, and insurance information. You will also need the name and contact information of the healthcare provider you wish to see out-of-network.
2. Understand your insurance policy: Familiarize yourself with your insurance policy to determine if you are covered for out-of-network services. Review the terms and conditions regarding referrals, coverage limits, and any required pre-authorization.
3. Obtain the out-of-network referral form: Contact your insurance provider or download the form from their website. Make sure you have the most recent version of the form to avoid any discrepancies.
4. Complete the patient information section: Enter your personal details as accurately as possible. Double-check your contact information to ensure the insurance provider can easily reach you if needed.
5. Fill in the healthcare provider information section: Provide the name, contact information, and specialty of the out-of-network provider you wish to see. If available, include the provider's National Provider Identifier (NPI) number.
6. Specify the reason for the referral: Indicate why you need to see an out-of-network provider, such as a unique medical condition or specialist expertise not available within your network.
7. Attach supporting documentation: If required by your insurance provider, include any supporting documents, such as medical reports, test results, or a letter of recommendation from your primary care physician. These documents can help demonstrate the medical necessity and justification for seeing an out-of-network provider.
8. Review and submit the form: Take a moment to review the completed form before submitting it. Ensure all information is accurate and legible. Submit the form according to your insurance provider's instructions, which may include mailing, faxing, or submitting it electronically.

Who needs an out-of-network referral form?

Those who need an out-of-network referral form typically include individuals who have health insurance coverage through a managed care plan or a network-based insurance policy. These individuals may need to see a healthcare provider outside their approved network due to factors such as geographical limitations, specialized medical requirements, or lack of in-network provider availability for a specific service or treatment.

It is important to consult your insurance policy and contact your insurance provider to determine if you need an out-of-network referral form. Not all insurance plans require a referral for out-of-network services, so it is crucial to understand your specific coverage and requirements.

For pdfFiller’s FAQs

What is out-of-network referral form?

Out-of-network referral form is a document used to request approval for medical services from a healthcare provider that is not in the patient's insurance network.

Who is required to file out-of-network referral form?

The patient or their healthcare provider is required to file the out-of-network referral form.

How to fill out out-of-network referral form?

To fill out the out-of-network referral form, one must provide their personal information, insurance details, healthcare provider information, reason for out-of-network service, and any supporting documentation as required.

What is the purpose of out-of-network referral form?

The purpose of the out-of-network referral form is to request authorization and assess the medical necessity of services provided by out-of-network healthcare providers.

What information must be reported on out-of-network referral form?

Information such as patient's personal details, insurance information, healthcare provider details, reason for out-of-network service, and any supporting documentation must be reported on the out-of-network referral form.

How can I send out-of-network referral form to be eSigned by others?

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