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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 Prior Authorization Request:

1. Start by gathering all necessary information: Before filling out a prior authorization request, it's important to collect all the required documents, such as the patient's medical records, prescription information, and any supporting documentation that might be needed for the request.
2. Identify the correct form: Each insurance company may have its own specific prior authorization form. Make sure to use the correct form provided by the insurer to avoid any delays or rejections.
3. Provide patient information: Begin by entering the patient's full name, date of birth, insurance identification number, and any other relevant personal information as required.
4. Include prescribing physician's details: Input the prescribing physician's name, contact information, and their National Provider Identifier (NPI) number. This information helps the insurer identify and verify the healthcare provider.
5. Fill in medication details: Specify the medication being requested for prior authorization. Include the drug name, strength, dosage form, and any other relevant details like quantity and directions for use.
6. Explain the medical necessity: In a separate section or field, describe the medical condition or diagnosis that requires the medication. Provide a detailed explanation of why the requested medication is necessary, including any failed treatments or potential risks associated with other alternatives.
7. Attach supporting documentation: If necessary, attach any additional documents that support the prior authorization request. This can include medical records, lab results, diagnostic reports, or letters of medical necessity from healthcare professionals.
8. Submit the request: Once you have filled out the form accurately and attached any required documents, submit the prior authorization request to the insurance company. Follow any specific submission instructions provided by the insurer, such as sending it electronically or through fax.

Who Needs Prior Authorization Request:

1. Patients requiring medications or treatments not typically covered by their insurance plan may need to go through the prior authorization process. This ensures that the treatment is necessary and appropriate before the insurer agrees to cover the costs.
2. Healthcare providers also need prior authorization when prescribing medications or treatments that fall under the insurer's review. This helps insurers control costs and ensure appropriate utilization of healthcare resources.
3. Insurance companies require the prior authorization request to assess the medical necessity of the requested treatment and verify that it aligns with the policy guidelines. This process helps protect the insurer and the patient by ensuring appropriate and cost-effective care.

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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 done or given.

Who is required to file prior authorization request?

Healthcare providers, such as doctors and hospitals, are required to file prior authorization requests with health insurance companies on behalf of their patients.

How to fill out prior authorization request?

The healthcare provider must complete the necessary forms provided by the insurance company and submit relevant medical information to support the request.

What is the purpose of prior authorization request?

The purpose of prior authorization request is to ensure that the proposed treatment or medication is medically necessary and appropriate, and to prevent unnecessary costs for both the patient and the insurance company.

What information must be reported on prior authorization request?

The prior authorization request must include details about the patient, the healthcare provider, the proposed treatment or medication, and the medical necessity for the requested service.