OptumRx Xarelto Prior Authorization Request Form 2017-2026 free printable template

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How to fill out OptumRx Xarelto Prior Authorization Request Form

How to fill out OptumRx Xarelto Prior Authorization Request Form

1. Obtain the OptumRx Xarelto Prior Authorization Request Form from the official website or your healthcare provider.
2. Complete the patient information section with the patient's full name, date of birth, and insurance details.
3. Fill out the prescriber information including the prescriber's name, contact information, and NPI number.
4. Indicate the patient's diagnosis and provide relevant medical history that supports the need for Xarelto.
5. List any previous medications attempted for the condition and the outcomes.
6. Include the dosage and frequency of Xarelto prescribed by the healthcare provider.
7. Attach any necessary clinical documentation such as lab results or progress notes that justify the use of Xarelto.
8. Sign and date the form, and ensure all sections are completed to avoid delays.
9. Submit the form to OptumRx via the provided fax number or online submission as instructed.
10. Follow up with OptumRx for confirmation and any additional requirements.

Who needs OptumRx Xarelto Prior Authorization Request Form?

1. Patients who have been prescribed Xarelto for a specific medical condition requiring prior authorization.
2. Healthcare providers who are prescribing Xarelto and need to obtain insurance approval for their patients.
3. Insurance companies or pharmacy benefits managers that require verification before covering the cost of Xarelto.

People Also Ask about

How do I get a prior authorization OptumRx?

To begin the PA process, you can: • Let your doctor know that a PA is needed for your medication. Call Optum Rx toll-free at 1-855-828-9834 (TTY: 711). How long does it take for a PA to be approved or denied? Once your PA has been submitted and received, it usually takes 48 to 72 hours to process.

How do I get my doctor to send my prescription to OptumRx?

Your doctor will need to submit a request to OptumRx to confirm that your medication is clinically appropriate for you. Please call (855) 828-9834 (TTY 711) for questions on this process.

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.

Why is it so hard to get a prior authorization?

Insurance companies can deny a request for prior authorization for reasons such as: The doctor or pharmacist didn't complete the necessary steps. Filling the wrong paperwork or missing information such as service code or date of birth.

How do I submit a prior authorization to OptumRx?

To begin the PA process, you can: • Let your doctor know that a PA is needed for your medication. Call Optum Rx toll-free at 1-855-828-9834 (TTY: 711). How long does it take for a PA to be approved or denied? Once your PA has been submitted and received, it usually takes 48 to 72 hours to process.

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.

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What is OptumRx Xarelto Prior Authorization Request Form?

The OptumRx Xarelto Prior Authorization Request Form is a document that healthcare providers must complete to obtain approval from OptumRx for a patient to receive Xarelto, a prescription medication used to prevent blood clots.

Who is required to file OptumRx Xarelto Prior Authorization Request Form?

Healthcare providers, such as physicians or specialists who prescribe Xarelto, are required to file the OptumRx Xarelto Prior Authorization Request Form on behalf of their patients.

How to fill out OptumRx Xarelto Prior Authorization Request Form?

To fill out the form, providers need to include patient information, details about the medical condition being treated, relevant previous treatments, and specific clinical information that supports the need for Xarelto.

What is the purpose of OptumRx Xarelto Prior Authorization Request Form?

The purpose of the form is to ensure that Xarelto is being prescribed appropriately and to confirm that the medication is medically necessary for the patient’s treatment before coverage is granted by OptumRx.

What information must be reported on OptumRx Xarelto Prior Authorization Request Form?

The information required includes patient demographics, diagnosis details, previous medication trials, rationale for choosing Xarelto, and any pertinent medical history that justifies the request.