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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 the prior authorization request, make sure you have all the required information on hand. This may include details about the patient, such as name, date of birth, and insurance information. Additionally, you might need information about the medication or treatment being requested, such as the name, strength, dosage, and quantity.
2. Complete the patient information section: Begin filling out the form by providing accurate and up-to-date information about the patient. Include their full name, address, contact number, and date of birth. Double-check these details to ensure accuracy.
3. Provide the insurance information: In this section, include the patient's insurance information, such as the name of the insurance company, policy number, and group number. Often, there will be additional information required, such as the primary care physician's name or the subscriber's ID if it differs from the patient's ID.
4. Specify the medication or treatment details: Fill out the section related to the medication or treatment for which prior authorization is being requested. Include as much information as possible, such as the name of the medication, dosage instructions, and the diagnosis for which it is being prescribed. If it's a treatment, provide details about the procedure or service being requested.
5. Attach supporting documentation: It is crucial to include any relevant supporting documents along with the prior authorization request. These may include medical records, test results, physician notes, or any other documentation that helps support the medical necessity of the requested medication or treatment. Make sure to label and organize these attachments properly to avoid confusion.
6. Follow submission guidelines: Each insurance company or healthcare provider may have specific submission guidelines for prior authorization requests. Ensure that you comply with these guidelines and requirements. This might include using specific forms, submitting electronically or via fax, or adhering to certain timeframes for submission.

Who needs prior authorization request:

1. Insurance companies: Most insurance companies require prior authorization for certain medications, treatments, or procedures. They use this process to ensure that their policyholders receive appropriate and medically necessary care while managing healthcare costs.
2. Healthcare providers: Physicians, hospitals, and other healthcare providers, may need to initiate a prior authorization request when prescribing medications or recommending medical procedures that require insurance pre-approval. This helps ensure that the insurance will cover the cost of the prescribed treatment or procedure.
3. Patients: Patients may need to be aware of the prior authorization process if they are prescribed a medication or recommended a treatment that requires insurance approval. They might need to work with their healthcare provider and insurance company to ensure the prior authorization request is submitted correctly and that their treatment is covered.

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What is prior authorization request?

Prior authorization request is a process by which a healthcare provider must obtain approval from a patient's insurance company before performing a specific service or procedure.

Who is required to file prior authorization request?

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

How to fill out prior authorization request?

To fill out a prior authorization request, healthcare providers must provide patient information, details of the requested service or procedure, and any supporting documentation.

What is the purpose of prior authorization request?

The purpose of prior authorization request is to ensure that the recommended treatment or service is medically necessary and cost-effective.

What information must be reported on prior authorization request?

The prior authorization request must include the patient's demographics, medical history, diagnosis, treatment plan, and any relevant clinical documentation.