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Prior Authorization Request Send completed form to: Case Review Unit CVS/earmark Specialty Programs Fax: 8662496155 CVS/earmark administers the prescription benefit plan for the patient identified.

How to fill out prior authorization request

How to fill out a prior authorization request:

1. Gather the necessary information: Before filling out the prior authorization request form, make sure to gather all the relevant details such as patient demographics, insurance information, prescribing physician's name, and the specific medication or procedure requiring authorization.
2. Review the form carefully: Read through the prior authorization request form thoroughly to understand the required fields, supporting documentation needed, and any specific instructions or guidelines provided by the insurance company or healthcare provider. This will ensure that you provide all the necessary information accurately.
3. Provide patient information: Fill out the patient's personal details such as name, date of birth, address, and contact information. Double-check for any spelling errors or inaccuracies.
4. Include insurance details: Enter the patient's insurance information, including the insurance company's name, policy number, and any necessary group or plan numbers. This information is crucial for the insurance company to evaluate the coverage and eligibility.
5. Specify the medication or procedure: Clearly indicate the specific medication or procedure requiring authorization. Include relevant details like the dosage, frequency, and duration of the medication or the nature of the procedure. Providing any supporting documentation, such as medical records or clinical notes, can further strengthen the authorization request.
6. Attach supporting documentation: If there are any supporting documents required for the prior authorization request, ensure they are securely attached. These documents may include medical records, test results, diagnosis codes, treatment plans, or any other relevant information that can support the need for the medication or procedure.
7. Explain the medical necessity: In a separate section or a designated field, provide a clear and concise explanation of the medical necessity for the requested treatment. Use specific medical terminology and provide any additional information that can justify the need for prior authorization. Be sure to mention any previous treatments attempted, their outcomes, and why the requested medication or procedure is considered essential for the patient's well-being.
8. Verify provider information: Include the information about the prescribing physician, including their full name, credentials, and contact details. The insurance company may need to reach out to the provider for further clarification or additional information if required.
9. Review and double-check: Before submitting the prior authorization request, thoroughly review all the entered information for accuracy and completeness. Any mistakes or missing information can delay the approval process or even result in denial.

Who needs prior authorization request?

1. Health insurance companies often require prior authorization for specific medications, procedures, or treatments to ensure they are medically necessary and meet their coverage criteria. It is essential to check with the patient's insurance provider to determine if prior authorization is necessary for a particular medication or procedure.
2. Healthcare providers, including physicians, specialists, and healthcare facilities, typically initiate the prior authorization process. They need to submit the request to the insurance company on behalf of the patient to obtain approval for the medication or procedure that falls under the prior authorization requirement.
3. Patients who require a medication or procedure that is subject to prior authorization need to be aware of the process. They should understand the importance of working closely with their healthcare provider to provide accurate information and any requested documentation to facilitate a smooth prior authorization request. Patients should also be prepared for the possibility of a waiting period before receiving approval from the insurance company.

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What is prior authorization request?

Prior authorization request is a process used by health insurance companies to determine if they will cover a prescribed procedure, service, or medication before it is provided to the patient.

Who is required to file prior authorization request?

Healthcare providers, pharmacies, and sometimes patients are required to file prior authorization requests with the insurance company.

How to fill out prior authorization request?

Prior authorization requests can typically be filled out online, over the phone, or by submitting a form provided by the insurance company.

What is the purpose of prior authorization request?

The purpose of prior authorization requests is to ensure that the prescribed treatment is medically necessary and cost-effective before it is provided to the patient.

What information must be reported on prior authorization request?

Information such as patient's demographics, insurance information, provider's information, diagnosis, treatment plan, and supporting medical records must be reported on the prior authorization request.