If you need to complete the Carelon Preauthorization/RQI Request Form, this guide will walk you through the process to ensure your submission is accurate and processed without delay.

What is the Carelon Preauthorization Form?

The Carelon Preauthorization Form is used to request prior authorization for medical procedures, tests, or treatments. Completing the form accurately is critical for avoiding delays in care. Whether you’re a healthcare provider or a patient managing your own care, this guide will help you navigate the process.

Step-by-Step Instructions

1. Download the Form

• Where to Get It: Download the form from Carelon’s official website or obtain it from your healthcare provider.
• Fillable Version: If available, use the fillable PDF version to streamline the process.

2. Read the Instructions Carefully

• Urgent Requests: If your request is urgent, call Carelon directly as specified on the form. Fax submissions for urgent requests are not recommended.
• Complete All Fields: Incomplete forms will be returned, so ensure every section is filled out accurately.

3. Enter Subscriber and Patient Information

This section captures the details of the person covered under the health plan and the patient receiving care.

• Subscriber Name: Enter the full name of the insurance policyholder.
• Patient Name: Provide the full name of the patient, if different from the subscriber.
• Insurance ID Number: Include the full insurance ID, ensuring the alpha prefix is present.
• Date of Birth (DOB): Input the patient’s DOB in MM/DD/YYYY format.
• Sex: Mark the appropriate box (M for male, F for female).
• Relationship to Subscriber: Specify if the patient is the subscriber, spouse, or dependent.
• Health Plan Name and Group Number: Provide the name of the insurance plan and the group number from the insurance card.
• Product Type: Indicate whether the insurance is PPO, POS, HMO, or another type.

4. Provide Referring Physician Information

This section details the physician ordering the procedure.

• Physician Name: Enter the first and last name of the physician.
• Specialty: Indicate the physician’s area of expertise (e.g., cardiology, oncology).
• Contact Details: Provide the physician’s phone and fax numbers.
• Practice Address: Include the full address of the physician’s practice.

5. Fill Out Provider Information

Provide the details of the facility where the procedure will occur.

• Facility Name: Enter the name of the medical facility.
• Contact Numbers: Include the facility’s phone and fax numbers.
• Facility Address: Provide the complete address of the facility.

6. Add Procedure Information

This section documents the procedure being requested.

• Procedure Date: Specify the scheduled date of the procedure.
• Procedure Description: Clearly describe the procedure (e.g., MRI of the lower back).
• CPT Code: If available, include the appropriate CPT code for the procedure. CPT codes are crucial for insurance processing.

7. Include Clinical Information

This is the most critical section, providing the medical justification for the requested procedure.

• Diagnosis or Symptoms: Describe the patient’s condition, including how long symptoms have been present, their frequency, and intensity.
• Purpose of Procedure: State what the physician is trying to confirm or rule out.
• Previous Treatments: Detail any treatments already administered for the condition, including their type and duration.
• Past Testing: List relevant tests (e.g., lab work, imaging studies) and their results.
• Injury-Related: Indicate if the procedure relates to an injury, and if so, provide the injury date and type.
• Cancer Protocol: If the procedure is part of a post-chemo or radiation protocol for cancer, specify the cancer type.

8. Verify Accuracy

Before submission:

• Review the entire form for completeness.
• Ensure all required fields are filled in accurately.

9. Submit the Form

• Fax Submission: Fax the completed form to 800-610-0050 as instructed.
• Keep a Copy: Retain a copy of the form for your records in case follow-up is required.

10. Follow Up

• If you haven’t received a response within the expected timeframe, contact Carelon directly to inquire about your request’s status.

Helpful Tips

• Access to Information: Have the patient’s insurance card, medical records, and procedure details handy before starting.
• Urgent Cases: Avoid faxing for urgent requests; use the phone contact provided on the form.

This straightforward guide ensures you can complete and submit the Carelon Preauthorization Form without errors. If you have additional questions, reach out to Carelon or your healthcare provider for assistance.

Let me know if you’d like further refinements or formatting suggestions!

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