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Unison Health Plan Pharmacy Department Pharmacy Medical Exception Request Worksheet Please complete and return via fax to 412-457-1328 or 866-639-7785 () PATIENT NAME D.O.B. / / MEMBER ID# DURATION

How to fill out prior authorization request form

How to fill out a prior authorization request form:

1. Gather all necessary information: Before you start filling out the form, make sure you have all the required information on hand. This may include the patient's name, date of birth, insurance information, diagnosis, and medication details.
2. Review the instructions: Read through the instructions provided with the form to ensure you understand the process and any specific requirements. Pay attention to deadlines, supporting documentation needed, and any special instructions for completing the form.
3. Fill out patient information: Begin by filling out the patient's personal information, such as their name, address, date of birth, and contact details. Double-check to ensure accuracy and legibility.
4. Provide insurance details: Include the patient's insurance information, such as the insurance company's name, policy number, and group number. This is crucial for authorization purposes, as well as for billing and claims processing.
5. Specify the requested service or medication: Clearly state the specific service or medication that requires prior authorization. Include relevant details such as the name, dosage, frequency, and duration if applicable. Make sure to use the correct codes and descriptions as required by the form.
6. Attach supporting documentation: If the prior authorization request requires supporting documentation, such as medical records, test results, or a physician's note, make sure to gather and attach them to the form. Ensure that all attachments are labeled and organized appropriately.
7. Complete the healthcare provider section: If you are a healthcare provider completing the form on behalf of the patient, fill out your information accurately. Include your name, contact details, professional identification numbers (if required), and any additional details requested.
8. Review and sign: Before submitting the form, carefully review all the information you entered for accuracy and completeness. Make sure all required fields are filled out appropriately. Finally, sign and date the form as required.

Who needs a prior authorization request form:

1. Patients seeking specific medical services or medications: Prior authorization is typically required by insurance companies for certain services or medications that may require additional justification or authorization before coverage is granted. This can include procedures, surgeries, high-cost prescription drugs, or treatments.
2. Healthcare providers: Healthcare providers, such as physicians, specialists, or pharmacies, who wish to obtain coverage for their patients' prescribed services or medications may need to fill out a prior authorization request form. This ensures that the requested services or medications are medically necessary and comply with insurance coverage guidelines.
3. Insurance companies: Insurance companies utilize prior authorization request forms to evaluate and approve or deny coverage for certain medical services or medications. This process helps manage costs and ensure the appropriateness of the requested services based on the patient's specific insurance plan.

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