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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 all necessary information: Before starting the request, collect all relevant details such as the patient's name, contact information, date of birth, insurance information, and the specific procedure or medication requiring prior authorization.
2. Review the insurance policy: Familiarize yourself with the specific guidelines and requirements outlined in the patient's insurance policy regarding prior authorizations. This will help ensure that you provide all the necessary information and documentation.
3. Complete the authorization form: Many insurance companies have their own prior authorization forms, which can usually be found on their website or obtained from the healthcare provider's office. Fill out the form accurately, providing all the requested information. Double-check for any errors or omissions before submitting.
4. Include supporting documentation: Depending on the procedure or medication being requested, you may need to attach additional documentation to support your authorization request. These documents can include medical records, test results, prescriptions, or letters of medical necessity from the healthcare provider.
5. Submit the request: Once the prior authorization form is completed and all necessary documents are attached, submit the request to the appropriate insurance company. It is recommended to keep a copy of the submitted form and any supporting documents for your records.

Who needs a prior authorization request:

1. Patients seeking specific medical procedures: Certain medical procedures, such as surgeries, hospitalizations, specialty consultations, or high-cost diagnostic tests, may require prior authorization from the insurance company. This ensures that the procedure is deemed medically necessary and covered under the patient's insurance plan.
2. Patients requiring certain medications: Insurance companies often require prior authorization for certain medications, especially those that are costly or have specific usage restrictions. This step helps the insurance company determine if the medication is appropriate for the patient's condition and if there are any alternative, more cost-effective options available.
3. Healthcare providers and their staff: Physicians, nurses, or other healthcare providers and their administrative staff are responsible for initiating and completing the prior authorization process on behalf of their patients. They must ensure that the request is properly filled out and all necessary documentation is provided to support the authorization.

Remember, the specific requirements for prior authorizations may vary between insurance companies and policies. It is crucial to thoroughly review the insurance policy and guidelines for each individual patient to accurately complete the prior authorization request.

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What is prior authorization request?

Prior authorization request is a process used by healthcare providers to obtain approval from a patient's insurance company before providing a specific service or medication.

Who is required to file prior authorization request?

Healthcare providers such as doctors, hospitals, and pharmacies are typically required to file prior authorization requests.

How to fill out prior authorization request?

To fill out a prior authorization request, healthcare providers must provide the patient's information, treatment details, medical necessity, and supporting documentation.

What is the purpose of prior authorization request?

The purpose of prior authorization request is to ensure that the requested service or medication is medically necessary and meets the insurance company's guidelines for coverage.

What information must be reported on prior authorization request?

The prior authorization request must include patient demographics, healthcare provider information, diagnosis codes, treatment codes, and supporting clinical documentation.