Thank you for your interest in submitting a pre-certification request via web-form. At this time, the web-form is only available on tablets, laptops, and desktops.

Patient or Patient Healthcare representative: Utilization Review Plan Requirements - The following states have specific pre-cert requirements, please click on your state if listed below, if not, proceed below. If your state requires one of these special forms, please submit it via email to records@urmedwatch.com or by fax to (407) 333-8928.

If you do not receive a response please contact MedWatch to verify that your information has been transmitted to us. We can be reached at 1-800-432-8421 from 7am-9pm ET Monday through Friday.
AZ - Medication DME MedicalDevice
AZ - Standard Prior Auth for Health Services Form
TX - IRO General Information
TX - Request for a Review by an Independent Review Organization Form

You have accessed the MedWatch precertification form. Please enter as much information as possible in the spaces provided, even if you do not have all the information requested on this form. The data from this website is received daily during our regular business hours. You will receive a response within 24 hours of the first business day following the referral.
   

Insurance Information
Insurance Company Name
Group Name / ID
Precert Type
v
IMPORTANT: ICDs/CPTs must be added one at a time. Please click to Add to add an entry.
Once completed, click Save.
Diagnoses
Diagnosis 
Add
No Diagnoses have been added
Procedures
Procedure 
Procedure Date 
Add
No Procedures have been added
DME Cost (Monthly rental or purchase price)
Infusions, Injections, Specialty Drug (Cost per dose)
Admit Date
v
Discharge Date
v
Member PPO Network
Is this Primary Insurance
v
If no, who is Primary Insurance Carrier
Patient Information
Member ID
Last Name
First Name
Date of Birth
v
Gender
v
Address
City
State/Province
Zip/Postal Code
Phone
E-Mail
Insured Information
Member ID
Last Name
First Name
Date of Birth
v
Gender
v
Address
City
State/Province
Zip/Postal Code
Phone
E-Mail
Referring/Ordering Physician
EIN / Tax ID
NPI
Last Name
First Name
Specialty
Type
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Is Physician In Network
v
Address
City
State/Province
Zip/Postal Code
Phone
Fax
E-Mail
Facility/Agency
Provider Type
v
EIN / Tax ID
NPI
Will this service be billed on a UB04 or HCFA 1500?
v
Facility/Agency Name
Is Facility/Agency In Network
v
Address
City
State/Province
Zip/Postal Code
Phone
UR Contact Name
UR Phone
UR Fax
Submitter Information
Name
Phone
Fax
E-Mail
Do you have a Benefits & Eligibility or CRM Reference # for this request?
v
What is the Reference #
Relationship to Patient
v
Notes (Reason for Precertification/Referral)
Submission of this data to MedWatch does not verify certification, benefits, or coverage. Please contact MedWatch at 1-800-432-8421 for certification questions. Please contact your claims office for benefits or payment information.
**This office does not pay for records. If there is a fee, please contact 800-432-8421.
A verbal report is acceptable**
Send Precert Request