Pre-authorization request form

  • Release version: Yokohama
  • Updated January 30, 2025
  • 1 minute to read

    • The Pre-authorization request form includes the details of the pre-authorization request provided by a payer for a patient.

    Table 1. Pre-authorization request form fields

    Field

    Description

    Primary pre-auth number

    Primary pre-authorization number generated by the payer organization.

    Secondary pre-auth number

    Secondary pre-authorization number generated by the payer organization.

    Primary diagnosis

    Main condition in a patient submitted by the practitioner as the reason for the healthcare service requested in the pre-authorization request.

    Medication prescription

    Medication prescription for which the pre-authorization request is created for the patient.

    Status

    Approval status of the pre-authorization request.

    Date approved

    Date when the pre-authorization request was approved by the payer organization.

    Valid from

    Start date of the pre-authorization request validity period.

    Valid until

    End date of the pre-authorization request validity period.

    Notes

    Instructions or explanation for the pre-authorization request.