Visional — Submit a PA Case

Patient information

Basic demographics and insurance details for the PA request.

First name *

Last name *

Date of birth *

MRN / Chart ID

Insurance plan *

Member ID

Group number

Referring provider

⚠ Step therapy note: UnitedHealthcare requires documentation of ≥3 months of conventional systemic therapy failure before approving most biologic therapies for psoriasis. Ensure chart notes are included.

Diagnosis & biologic selection

Select the primary ICD-10 diagnosis and the biologic being requested.

Primary diagnosis *

Secondary diagnosis (optional)

Biologic requested *

Cards shown are relevant to the selected diagnosis.

Specialty pharmacy

Supporting documents

Upload chart notes, labs, and photos. PDFs and images accepted.

📎

Click to upload or drag files here

PDF, JPG, PNG — max 20 MB each

Urgency level *

Standard

2–3 business days

Urgent

Same day / 24 hr

Expedited appeal

Denial reversal needed

Internal notes to DermAuth team

Initial Prior Authorization

Visional has access to your EMR — just give us the essentials and we'll handle the rest.

Practice name *

Your name *

Your email *

Your phone

Patient name *

Patient date of birth *

Diagnosis *

Desired medication *

Mode of PA submission *

Prior auth request form

Upload the PA request form OR enter the key details below

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Upload PA request form (optional)

PDF, JPG, PNG — max 20 MB

Prior auth key / Reference #

Pharmacy claim / Reference #

Additional notes

Appeal Request

Submit an appeal for a denied prior authorization. Visional will prepare and submit the appeal on your behalf.

Practice name *

Your name *

Your email *

Your phone

Patient name *

Patient date of birth *

Diagnosis *

Medication denied *

Mode of appeal submission *

Denial letter

Upload the denial letter OR enter the rejection details below

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Upload denial letter (recommended)

PDF, JPG, PNG — max 20 MB

Rejection code

Reason for denial

Additional notes

✅

Case submitted successfully

Your PA case has been received. Our clinical team will review and begin submission within 2 business hours. You'll receive email updates on every status change.

DA-2024-00847