Superior Health Plan Pa Request Form Details

If you are a healthcare provider, then you know that prior authorization is an important part of the process for getting approvals for treatments and procedures. In order to make the process as smooth as possible, it is important to have a quality prior authorization form. The Superior Prior Authorization Form is designed specifically for this purpose, and it can help you get approvals quickly and easily. This form is available free of charge on our website, and we encourage you to download it today.

We've collected some statistical information regarding the superior prior authorization form. You'll have the assumed time it might require you to fill in the form as well as additional details.

QuestionAnswer
Form NameSuperior Prior Authorization Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namessuperior healthplan prior authorization form, superior prior auth form pdn ccp, superior request for prior authorization form, prior auth request form superior

Form Preview Example

MEDICATION PRIOR AUTHORIZATION REQUEST FORM SUPERIOR HEALTH PLAN, TEXAS

(*Do Not Use This Form for Biopharmaceutical Products*)

FAX this completed form to 866-399-0929

OR Mail requests to: US Script PA Dept., 2425 West Shaw Avenue, Fresno, CA 93711

Call 800-460-8988 to request a 72-hour supply of medication.

I. Provider Information

 

II. Member Information

 

 

 

Prescriber name (print):

 

Member name:

 

 

 

Prescriber Specialty:

 

Identification number:

 

 

 

Fax:

Phone:

Date of Birth:

 

 

 

Office Contact Name:

 

Medication allergies:

 

 

 

III.Drug Information (One drug request per form)

Drug name and strength:

Dosage form:

Dosage interval (sig):

Qty per Day:

Diagnosis relevant to THIS request:

Expected length of therapy:

Medication History for this Diagnosis

A.Is member currently treated on this medication?

yes; How Long?_______________ [go to item B]

no [skip items B & C; go to item D]

B.Is this request for continuation of a previous approval?

yes [go to item C]

no [skip item C; go to item D]

C.Has strength, dosage, or quantity required per day increased or decreased?

yes [go to item D]

 

no [skip item D; indicate rationale for continuation in Section IV and submit form]

D.Please indicate previous treatment and outcomes below.

Drug Name (include strength and dosage)

Dates of Therapy

Reason for Discontinuation

1

2

3

4

NOTE: Confirmation of use will be made from member history on file; prior use of preferred drugs is a part of the exception criteria.

IV. Rationale for Request / Pertinent Clinical Information (Required for all Prior Authorizations)

Appropriate clinical information to support the request on the basis of medical necessity must be submitted.

Provider Signature:

Date:

US Script will respond via fax or phone within 24 hours of receipt of all necessary information, except during weekends and holidays. Requests for prior authorization (PA) must include member name, ID#, and drug name. Incomplete forms will delay processing. Please include lab reports with requests when appropriate (e.g., Culture and Sensitivity; Hemoglobin A1C; Serum Creatinine; CD4; Hematocrit; WBC, etc.).

MHP Revised 01-2011