OPTUMRx Movantik Prior Authorization Request Form 2015 free printable template

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How to fill out OPTUMRx Movantik Prior Authorization Request Form

How to fill out OPTUMRx Movantik Prior Authorization Request Form

1. Obtain the OPTUMRx Movantik Prior Authorization Request Form from the OPTUMRx website or your healthcare provider.
2. Fill in patient information including name, date of birth, and insurance details.
3. Provide the prescribing physician's information including name, contact number, and NPI number.
4. Indicate the diagnosis for which Movantik is being requested, along with relevant medical history.
5. Document any previous treatments attempted for the same condition and their outcomes.
6. Include necessary lab test results or other supporting documents as required.
7. Sign and date the form to authorize the release of medical information.
8. Submit the completed form via the specified method (fax, email, or mail) to the designated OPTUMRx prior authorization department.
9. Follow up with the provider's office to ensure the request has been received and is being processed.

Who needs OPTUMRx Movantik Prior Authorization Request Form?

1. Patients prescribed Movantik for opioid-induced constipation who have insurance coverage requiring prior authorization.
2. Healthcare providers submitting an authorization request on behalf of their patients.

People Also Ask about

What is the phone number for OptumRx PA?

Submitting a PA request to OptumRx via phone or fax above. For urgent requests, please call us at 1-800-711-4555. (Hours: 5am PST to 10pm PST, Monday through Friday.)

What is the fax number for Optum PA specialty?

Send us the PA via electronic prior authorization (ePA) available through CoverMyMeds. Alternatively, you can fax it to us at 1.800. 218.3221.

How do I fax a prescription to OptumRx?

Fax 1-800-491-7997 – Send a complete prescription using the Physician Fax Form. Please do the following prior to submitting the prescription for your patient: Verify with your patient if they wish to use Optum® Home Delivery as their pharmacy.

How do I submit a prior authorization to OptumRx?

Submitting a PA request to OptumRx via phone or fax above. For urgent requests, please call us at 1-800-711-4555. (Hours: 5am PST to 10pm PST, Monday through Friday.)

What is the fax number for OptumRx specialty prior authorization?

Fax this form to: 1-866-434-5523 Phone: 1-866-434-5524 OptumRx will provide a response within 24 hours upon receipt.

How do I appeal a prior authorization denial OptumRx?

Call OptumRx customer service at 888-239-1301 or. Call the OptumRx prior authorization team at 800-711-4555 or. Have your provider fax OptumRx at 844-403-1028.

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What is OPTUMRx Movantik Prior Authorization Request Form?

The OPTUMRx Movantik Prior Authorization Request Form is a document that healthcare providers must complete to request approval from OPTUMRx for the coverage of the medication Movantik for a patient.

Who is required to file OPTUMRx Movantik Prior Authorization Request Form?

Healthcare providers, such as doctors and prescribing clinicians, are required to file the OPTUMRx Movantik Prior Authorization Request Form on behalf of their patients.

How to fill out OPTUMRx Movantik Prior Authorization Request Form?

To fill out the OPTUMRx Movantik Prior Authorization Request Form, providers should gather the necessary patient information, complete the requested clinical information, and submit the form according to OPTUMRx submission guidelines.

What is the purpose of OPTUMRx Movantik Prior Authorization Request Form?

The purpose of the OPTUMRx Movantik Prior Authorization Request Form is to ensure that the use of Movantik is medically necessary and qualifies for insurance coverage before the medication is prescribed.

What information must be reported on OPTUMRx Movantik Prior Authorization Request Form?

The form must report patient demographic information, prescribing provider details, diagnosis codes, treatment history, and any pertinent clinical information that supports the need for Movantik.