Prior Authorization Request (Outpatient), Continued Step Fill in the required 6 information for Procedure Codes (CPT). Step Enter the Start 6.1 Date and End Date using the calendar dropdowns. Step the quantity. 6.2 If appropriate, select the number of Units, Visits, etc. from the Frequency dropdown, the rate, and the model number. Continued on next page Prior Authorization Request (Outpatient), Continued Step If appropriate, 6.3 choose the modifier from the dropdown. A new field displays after you enter one. The maximum number of modifiers is 3. Step If you want to 6.4 add a second code, delete the original entry and enter the new code or description. Search for the code using the Code Starts With or Description (1) fields. Click Find (2).
Prior Authorization Request (Outpatient), Continued Step 6 Fill in the required information for Procedure Codes (CPT). Step 6.1 Enter the Start Date and End Date using the calendar dropdowns. Step 6.2 the quantity. If appropriate, select the number of Units, Visits, etc. from the Frequency dropdown, the rate, and the model number. Continued on next page Prior Authorization Request (Outpatient), Continued Step 6.3 If appropriate, choose the modifier from the dropdown. A new field displays after you enter one. The maximum number of modifiers is 3. Step 6.4 If you want to add a second code, delete the original entry and enter the new code or description. Search for the code using the Code Starts With or Description (1) fields. Click Find (2).
MNEMAAtrezzoProviderPortalEndUserGuidev1.docx