Request For Preauthorization Of Medical Treatment {25PR}

FORM 25PR (PROVISIONAL) - REQUEST FOR PREAUTHORIZATION OF MEDICAL TREATMENT. This form is used in North Carolina workers’ compensation cases to request advance approval for certain medical services, including surgery or inpatient hospital admission. Form 25PR must be completed and submitted by the treating health care provider to the workers’ compensation insurer or designated preauthorization agent, as required under the Workers’ Compensation Act. The form collects information about the employee, injury date, diagnosis, requested procedure, treatment setting, and supporting clinical documentation. It also includes a section for the insurer to approve or deny the request and provide a preauthorization number. Page two is used by a reviewing provider to appeal an initial denial, including peer-to-peer review details and medical findings supporting authorization. www.FormsWorkflow.com