Prior Authorization Request Form – Fill Out and Use This PDF

Completing a Prior Authorization Request Form can seem like a tedious task. However, submission of the form is an important step to ensure appropriate and necessary health care services are received. Gathering all pertinent information and organizing it in one place will facilitate completion of the request for authorization quickly and accurately. Obtaining prior authorization guarantee coverage for service prescribed by physicians thus avoiding unbudgeted out of pocket costs for healthcare. It is in the best interest of both individuals as well as organizations to take time to complete and comply with the Prior Authorization rules and regulations. This can save everyone time, effort, money and immense amount of frustration from back-and forth inquiry between providers, organizations and insurers.

Get Form Now Download PDF

Prior Authorization Request Form PDF Details

Are you looking for an efficient way to process prior authorization requests? Are you seeking a streamlined way to secure the care and treatments your patients need as quickly as possible? If so, then creating a detailed and complete Prior Authorization Request Form may be the answer. In this blog post, we’ll review all of the key elements that should be included when creating such a form and provide tips for optimizing it in order to ensure smooth processing by insurance companies.

Question	Answer
Form Name	Prior Authorization Request Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	optumrx prior auth printable form, optumrx prior authorization request form to print, optumrx medication prior authorization form, optumrx prior authorization request form

Form Preview Example

Prior Authorization Request Form

Fax Back To: 1-800-853-3844

Phone: 1-800-711-4555

5 AM – 7 PM PST M-F

Prior Authorization Form

Patient Information

Patient’s Name:

Insurance ID:	Date of Birth:	Height:		Weight:
Address:		Apartment #:
City:	State:	Zip:
Phone Number:	Alternate Phone:	Sex:	Male	Female
Provider Information
Provider’s Name:	Provider ID Number:
Address:	City:	State:		Zip:
Suite Number:	Building Number:
Phone Number:	Fax number:
Provider’s Specialty:
Medication Information
Medication:	Quantity:	ICD9 Code:
Directions:	Diagnosis:	Refills:
Will the physician supply this medication?		Yes	No

By providing the information it will only be used for coverage determination request administered by OptumRx.

Medication Instructions

Has the patient been instructed on how to Self-Administer?		Yes	No
Is this medication a New Start?		Yes	No
If NO please provide the following:	Initiation Date: / /	Date of Last Dose: / /

This is to notify you that your patient’s request for this medication may be denied unless we receive supportive information, i.e., medications tried and failed, document improvement with medication(s). Please provide information to support this request. Please fax back at the number listed above or call at 1-800-711-4555.

Administration Instructions

Dispensing Location: Physician’s Office

Patient’s Address

Date medication is needed: / /

Medication Administered: Home Health Self Administered LTC Physician’s Office

*If you have any questions regarding your patient’s plan drug limits you may call us at: 1-800-711-4555.

______________________________________________________________________________________________________________

This electronic fax transmission, including any attachments contains information from OptumRx that may be confidential and/or privileged. The information contained in this facsimile is intended to be for the sole use of the individual(s) or entity named above. If you are not the intended recipient, be aware that any disclosure, copying, distribution or use of the contents of this information is strictly prohibited by law and will be vigorously prosecuted. If you have received this electronic fax transmission in error, please notify the sender immediately and return the document(s) by mail to OptumRx Privacy Office, 2300 Main St., M/S CA134-0501, Irvine, CA 92614 www.optumrx.com BlankSpecialtyForm_Jan2013.doc

Enbrel-Humira-Remicade-Orencia-Kineret-Simponi-Cimzia-Actemra-Stelara

Patients Name: ___________________________________________

Patients ID#: ____________________ DOB: ___________________

OptumRx Specialty Prior Authorization (continued)

OptumRx

Fax # 1-800-853-3844

Page 2 of 2

Document the patient’s diagnosis: ______________________________ ICD-9 Code: _________________

_____________________________________________________________________________________________________________________

Please Document all that applies to the Patient

Has the patient been evaluated for tuberculosis and treated accordingly?	Yes		No
Document date of last PPD test: _________	Negative		Positive

For Diagnosis of Rheumatoid Arthritis or Ulcerative Colitis: Does the Patient exhibit symptoms of MODERATE to SEVERE?

Yes No

For Diagnosis of Psoriasis: Does the patient have failure, intolerance or contraindication to: (Please circle all that apply) Ultraviolet Light B (UVB), Pulsed Dye Laser, Photochemotherapy, Psoralen and exposure to Ultraviolet light a (PUVA)


For Diagnosis of Crohn’s Disease: Does the patient exhibit symptoms of MODERATE to SEVERE?		Yes	No
Has induction dose been prescribed? Yes	No (if NO document reason why it has not been prescribed)

_____________________________________________________________________________________________________________

Document if the patient has tried, failed or had contraindication

Methotrexate

Imuran (azathioprine)

Cyclosporine (Sandimmune, Neoral)

Gold compounds (Myochrisine, Ridura, Aurolate, and Solganal) Plaquenil (hydroxychloroquine)

Arava (leflonomide) Cuprimine (penicillamine)

Aminosalicylates (e.g. sulfasalazine, azulfidine, mesalamine)

6-mercaptopurine (Purnethol) NSAIDs (e.g. Ibuprofen)

6-thioguanine Acitretin (soriatane) Hydroxyurea (hydrea) Mycophenolate (cellcept) Corticosteroids

Please Document Dates of therapies for medications selected: __________________________________

Please document any clinical contraindications to these medications:_______________________________________________________

______________________________________________________________________________________________________________

Has the patient had a trial, failure or contraindication to any of the following medications? (Please list dosage and/or contraindication)

Enbrel®	Yes	No	Dosage / Contraindication
			_________________________
Humira®	Yes	No	_________________________

Remicaid®	Yes	No	_________________________

Orencia®	Yes	No	_________________________
Kineret®	Yes	No	_________________________
Simponi®	Yes	No	_________________________

Cimzia®	Yes	No	_________________________

Actemra®	Yes	No	_________________________
Stelara®	Yes	No	_________________________

____________________________________________________________________________________________________________

Continuation of Therapy

Has the patient utilized the medication in the past 45 days?	Yes	No
Has the patient had documented clinical improvement from ongoing therapy?	Yes	No

(Please document dose reduction or reason for high dose [if applicable])

*If the above information is not available, please attach the patient’s chart notes documenting clinical improvement.

*If you have any questions regarding your patient’s plan drug limits you may call us at: 1-800-711-4555.

For UHC members: Your patient’s prescription benefit requires that we review certain requests for coverage with the prescriber. You have prescribed a medication for your patient that requires Prior Authorization before benefit coverage can be provided. Please complete the following questions then fax this form to the toll free number listed below. Upon receipt of the completed form, prescription benefit coverage will be determined based on the plan’s rules

______________________________________________________________________________________________________________

Main St., M/S CA134-0501, Irvine, CA 92614 www.optumrx.com Enbrel-Humira-Kineret-Orencia-Remicade-Simponi-Cimzia-Actemra- Stelara_2012June.doc

How to Edit Prior Authorization Request Form Online for Free

optumrx prior authorization request form to print can be filled out online without difficulty. Just make use of FormsPal PDF tool to complete the task right away. To retain our tool on the forefront of efficiency, we aim to integrate user-driven features and improvements regularly. We are routinely thankful for any suggestions - assist us with revampimg the way you work with PDF documents. Starting is effortless! All you should do is stick to the next simple steps directly below:

Step 1: Open the PDF file inside our tool by clicking the "Get Form Button" above on this page.

Step 2: After you launch the PDF editor, you'll notice the document made ready to be filled in. Besides filling in various fields, you can also do some other things with the file, namely adding your own textual content, changing the original textual content, inserting graphics, affixing your signature to the document, and much more.

This PDF doc will require specific details; to guarantee correctness, you should heed the following guidelines:

1. First of all, while completing the optumrx prior authorization request form to print, start in the part that includes the following fields:

Filling out segment 1 in optumrx prior authorization form

2. Right after filling in the last part, go to the subsequent part and fill out all required particulars in these blanks - Patients Name, OptumRx, Fax, Page of, Patients ID DOB OptumRx, Yes No Negative Positive, Yes, For Diagnosis of Psoriasis Does, Methotrexate Imuran azathioprine, mercaptopurine Purnethol NSAIDs eg, and Please Document Dates of therapies.

Stage no. 2 for submitting optumrx prior authorization form

Always be extremely mindful while filling out Page of and Please Document Dates of therapies, as this is where most users make mistakes.

3. This next stage is going to be easy - fill out all the empty fields in Please Document Dates of therapies, Dosage Contraindication, Yes Yes, No No, If you have any questions, For UHC members Your patients, and This electronic fax transmission in order to complete the current step.

Part no. 3 in completing optumrx prior authorization form

Step 3: Just after double-checking your fields and details, click "Done" and you're done and dusted! Find your optumrx prior authorization request form to print when you register online for a free trial. Conveniently gain access to the pdf document in your FormsPal cabinet, along with any edits and changes all saved! FormsPal is devoted to the confidentiality of all our users; we ensure that all information processed by our tool is kept confidential.

Prior Authorization Request Form – Fill Out and Use This PDF

Prior Authorization Request Form PDF Details

Form Preview Example

How to Edit Prior Authorization Request Form Online for Free

Prior Authorization Request Form isn’t the one you’re looking for?

Related Documents