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Online Preauthorization Request

Online Preauthorization RequestMedingenuityAdmin2020-04-27T18:10:20+00:00

Step 1 of 6

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  • If you have a physical copy of the TDI Standard Prior Authorization Request Form for Health Care Services form already filled out, please click here.

    Claim Profile

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Treating Provider Information

  • Requesting Provider information

    Please include the Requesting Provider’s information who is seeking authorization.
  • Facility information

    Please include the Facility Information where the requested service would be performed.
  • Service requested & type of review

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • If other than requestor
  • MM slash DD slash YYYY
    When is the best time for an IMO team member to call the Peer-to-Peer contact above?
  • :
    Specific Peer to Peer Time
  • Submissions & Attachments

  • Where you would like the confirmation email sent to print or store for your records (all submitted fields included)?
  • MM slash DD slash YYYY
  • Attachments

    Please attach supporting clinical records to validate this request.

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