Get the free Regence Pre-Authorization Request Form.Regence Pre-Authorization Request Form, Yr 1-15

PreAuthorization Request Former Uniform Medical Plan (UMP) Members: Fax to: 1 (877) 6637526 or Mail to: PO Box 2998, Tacoma, WA 984012998For Commercial and Individual Members: Fax to: 1 (855) 2320085

How to fill out regence pre-authorization request formregence

How to fill out regence pre-authorization request formregence

1. To fill out the Regence pre-authorization request form, follow these steps:
2. Obtain a copy of the Regence pre-authorization request form.
3. Start by providing the patient's personal information, such as their full name, date of birth, and insurance ID number.
4. Next, provide details about the healthcare provider requesting the pre-authorization, including their name, contact information, and provider ID number.
5. Specify the requested service or treatment that requires pre-authorization. Include information such as the diagnosis, CPT code, and the estimated start and end dates of the treatment.
6. Attach any relevant supporting documents, such as medical records, test results, or treatment plans.
7. Provide details about the referring healthcare provider, if applicable.
8. Complete the insurance information section, including the name of the insurance plan, group number, and any other requested details.
9. Review the form for accuracy and completeness.
10. Sign and date the form to verify its authenticity.
11. Submit the filled-out form via the designated submission method, which may include mail, fax, or electronic submission.
12. Keep a copy of the completed form for your records.
13. Await a response from Regence regarding the pre-authorization request.

Who needs regence pre-authorization request formregence?

1. Regence pre-authorization request form is needed by individuals who are seeking healthcare services or treatments that require prior approval from Regence.
2. This form is typically required for services such as complex surgeries, expensive procedures, specialized treatments, or pharmaceuticals that may need pre-authorization to ensure coverage by Regence health insurance.
3. Healthcare providers who wish to request pre-authorization on behalf of their patients also need to fill out this form.

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What is regence pre-authorization request formregence?

Regence pre-authorization request formregence is a form used to request approval from Regence for certain medical services or procedures before they are performed.

Who is required to file regence pre-authorization request formregence?

Healthcare providers, hospitals, or clinics are required to file the Regence pre-authorization request form.

How to fill out regence pre-authorization request formregence?

To fill out the Regence pre-authorization request form, provide all necessary information about the patient, the requested medical service or procedure, and any supporting documentation.

What is the purpose of regence pre-authorization request formregence?

The purpose of the Regence pre-authorization request form is to ensure that the requested medical service or procedure is medically necessary and covered by the patient's insurance plan.

What information must be reported on regence pre-authorization request formregence?

The Regence pre-authorization request form must include information such as patient demographics, medical history, healthcare provider information, and details of the requested service or procedure.