Prior Authorization Submission Guide

Overview
Prior authorization is used to determine the medical necessity of certain healthcare services before they are provided. To ensure coverage, authorization must be requested and approved in advance. Services rendered without prior approval may result in claim denial.

When Is Prior Authorization Required?
Advance approval may be required for coverage of specific non-emergency services, treatments, or prescriptions.

Examples include:

• Admission to a hospital or skilled nursing facility
• Scheduled surgeries
• Advanced imaging (e.g., MRI, CT scan)
• Durable medical equipment (e.g., wheelchairs, oxygen supplies)

Do NOT Use This Form To:

• ❌ Submit an appeal
• ❌ Confirm member eligibility
• ❌ Verify coverage
• ❌ Request a guarantee of payment

How to Complete the Prior Authorization Request Form

SECTION I — Submission Information

Fill in the details of the person submitting the request:

• Submitter Name & Title
• Direct Phone & Fax Number
• Date: Enter the date the request is being submitted.

SECTION II — Member Information

Provide details about the patient receiving care:

• Member Name and Date of Birth
• Members Phone number
• Verda Member ID: This is found on the member’s insurance card.
• IPA/Medical Group: located on the insurance card.
• Select Gender : Male or Female.
• Subscriber Info: If different from the patient, provide the subscriber’s name

SECTION III — Review Type

Choose the appropriate type of review and add relevant details:

• Select Expedited/Urgent, Elective/Routine, or Extension/Renewal/Amendment.
• Clinical Reason: Briefly explain why the service is needed.
• Previous Authorization #: Include for Extension/Renewal/Amendment.

SECTION IV — Provider Information

Enter information for both providers involved (if applicable):

Requesting Provider/Facility

• Name, Address, Phone, Fax
• NPI Number & Specialty

Service Provider/Facility (where care will be given)

• Name, Address, Phone, Fax
• NPI Number & Specialty
• Primary Care Provider Name: Must match Verda Healthcare records.

SECTION V — Services Requested

Provide specific codes and dates:

• CPT/HCPC Codes: Procedure codes for requested services.
• Diagnosis Code (ICD-10) & Description
• # of Units: Quantity of services (e.g., visits, tests).
• Date(s) of Service

SECTION VI — Clinical Documentation

Include required documents to support the request:

• Medical records
• Lab reports
• Progress notes
• Other relevant supporting information