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Incomplete forms will be returned for additional information.  \n1. PRIORITY:  \n a. Standard  \n b. Date of Service – Services scheduled for this date:    \n c. Urgent – Provider certifies that applying the standard review time frame may seriously jeopardize the life or health of the member  \n2. PATIENT INFORMATION:  \n\n| a. First Name: | b. Last Name: |  | c. MI: |  | d. DOB (mm/dd/yyyy): |\n| --- | --- | --- | --- | --- | --- |\n| e. Gender:  Male  Female |  | f. Height: |  | g. Weight: |  |\n| h. Address: |  | i. City, State, Zip: |  | j. Phone Number: |  |\n| k. Health Plan ID \\#: |  | l. Group \\#: |  |  |  |\n\n3. ORDERING PHYSICIAN/CLINIC INFORMATION:  \n\n| a. Name: |  | b. TIN/NPI\\#: | c. Prescriber's Medicaid ID\\#: | d. Specialty: |\n| --- | --- | --- | --- | --- |\n| e. Contact Name: | f. Clinic Name: |  | g. Clinic Address: |  |\n| h. City, State, Zip: |  |  | i. Phone: | j. Fax or email: |\n\n4. RENDERING PHYSICIAN/CLINIC/FACILITY/PHARMACY INFORMATION:  Check if same as 3.  \n\n| a. Name: |  | b. TIN/NPI\\#: | c. Prescriber's Medicaid ID\\#: |  | d. Specialty: |\n| --- | --- | --- | --- | --- | --- |\n| e. Contact Name: | f. Physician/Clinic/Facility/Pharmacy Name: |  |  | g. Address: |  |\n| h. City, State, Zip: |  |  | i. Phone: |  | j. Fax or email: |\n\n5. REQUESTED MEDICAL PROCEDURE/COURSE OF TREATMENT/DEVICE INFORMATION:  \n\n| a. Service Type: |\n| --- |\n| b. Setting/CMS POS Code:  Outpatient  Inpatient  Home  Office  *Other |\n| c. *Please specify if other: |\n\n6. HCPCS/CPT/CDT CODES  \n\n| a. Latest ICD Code | b. HCPCS/CPT/CDT Code | c. Code Description | d. Medical Reason |\n| --- | --- | --- | --- |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n\nOther Clinical Information – Include/attach clinical/office notes, laboratory information, imaging reports, and any guiding documentation to support medical necessity. If this is an out-of-network request, please provide an explanation.  \n7. OTHER SERVICES (SEE INSTRUCTIONS)  \n\n| a. Type of Service: |  | b. Name of Therapy/Agency: |  |\n| --- | --- | --- | --- |\n| c. Units/Volume/Visits Requested: | d. Frequency/Length of Time Needed: |  | e.  Initial  Extension Previous Authorization \\#: |\n| f. Additional Comments: |  |  |  |\n\n8. PRESCRIPTION DRUG  \n\n| a. Diagnosis name and code: |  |  |  |\n| --- | --- | --- | --- |\n| b. Medication Requested | c. Strength | d. Dosing Schedule\u003Cbr>(including length of therapy) | e. Quantity per Month or Quantity Limits |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n| f. Is the patient currently treated with requested medication(s):  Yes  No\u003Cbr>If yes, when was treatment with the requested medication started? |  |  |  |\n| g. Explain the medical reasons for the requested medications, including an explanation for selecting these medications over alternatives: |  |  |  |\n| h. List any other medications patient will use in combination with requested medication: |  |  |  |\n\n9. PREVIOUS SERVICES/THERAPY (INCLUDING DRUG, DOSE, DURATION, AND REASON FOR DISCONTINUING PREVIOUS THERAPY)  \n\n| a. | Date Discontinued: |\n| --- | --- |\n| b. | Date Discontinued: |\n| c. | Date Discontinued: |\n\nAdditional Information – Please attach and submit any progress notes, lab data, discharge summaries, or other guiding documentation to support discontinuation of previous therapy and initiation of therapy with the requested medication along with a copy of the prescription.  \n10. ATTESTATION  \nI hereby certify and attest that all information provided as part of this prior authorization request is true and accurate.  \nProvider Signature:   Date:    \nDO NOT WRITE BELOW THIS LINE: FIELDS TO BE COMPLETED BY PLAN  \nAuthorization \\#:   Contact Name:    \nInstructions for OIR-B2-2180  \n1. Priority: Only one of the following options should","cbCaig5J2KIxeW5V","https://ap.wps.com/l/cbCaig5J2KIxeW5V","pdf",1071084,"English","# Priority\n# Patient Information\n# Ordering Physician/Clinic Information\n# Rendering Physician/Clinic/Facility/Pharmacy Information\n# Requested Medical Procedure/Course of Treatment/Device Information\n# HCPCS/CPT/CDT Codes\n# Other Services\n# Prescription Drug\n# Previous Services/Therapy\n# Attestation","[{\"question\":\"What information is required to submit a prior authorization request?\",\"answer\":\"All applicable information and required documentation must be provided. Incomplete forms are returned for additional information.\"},{\"question\":\"How should priority be selected on the form?\",\"answer\":\"Choose Standard if the request is not urgent and not scheduled. Select Date of Service if the service is scheduled for a future date, or Urgent if applying the standard review timeframe may seriously jeopardize the member’s life or health.\"},{\"question\":\"What must providers include to support the medical necessity request?\",\"answer\":\"Include/attach clinical or office notes, laboratory information, imaging reports, and guiding documentation. If the request is out-of-network, provide an explanation.\"}]","Prior Authorization Form for Medical Procedures, Courses of Treatment, or Prescription Drug Benefits - Updated | PDF",1789618851]