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Expedited requests require certification that the request is urgent and medically necessary; urgent (not life threatening) determinations target within 72 hours to avoid complications or severe pain.",{"name":70,"@type":61,"acceptedAnswer":71},"What happens if supporting clinical information is missing or required fields are incomplete?",{"text":72,"@type":64},"Incomplete forms will be rejected. 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Existing Authorization  Units   Standard requests- Standard Request-Determination within 14 calendar days of receiving all necessary information  \nExpedited Request-I certify this request is urgent and medically necessary to treat an injury, illness or condition Urgent requests- (not life threatening) within 72 hours to avoid complications and unnecessary sufering or severe pain.  \n* INDICATES REQUIRED FIELD    \n* Date of Birth  \nMEMBER INFORMATION   \n* Medicaid/Member ID Last Name, First (MMDDYYYY)  \nREQUESTING PROVIDER INFORMATION  \n* Requesting NPI * Requesting TIN Requesting Provider Contact Name  \nRequesting Provider Name Phone * Fax  \nSERVICING PROVIDER / FACILITY INFORMATION  \n  Same as Requesting Provider  \n*Servicing NPI *Servicing TIN Servicing Provider Contact Name  \nServicing Provider/Facility Name  \nAUTHORIZATION REQUEST  \n*Primary Procedure Code  \n(CPT/HCPCS) (Modifer)  \nAdditional Procedure Code  \nAdditional Procedure Code  \n(CPT/HCPCS)  \nAdditional Procedure Code  \nPhone Fax  \n*Start Date OR Admission Date  \n(Modifer) (MMDDYYYY)  \nEnd Date OR Discharge Date  \n* Diagnosis Code  \n(ICD-10)  \nTotal Units/Visits/Days  \n*1126*  \n(CPT/HCPCS) (Modifer) (CPT/HCPCS) (Modifer) (MMDDYYYY)  \n\n| *OUTPATIENT SERVICE TYPE (Enter the Service type number in the boxes)  |  |  |\n| --- | --- | --- |\n| 412 Auditory\u003Cbr>422 Biopharmacy\u003Cbr>712 Cochlear Implants & Surgery\u003Cbr>299 Drug Testing\u003Cbr>922 Experimental and Investigational Services\u003Cbr>205 Genetic Testing & Counseling\u003Cbr>249 Home health\u003Cbr>390 Hospice Services\u003Cbr>290 Hyperbaric Oxygen Therapy\u003Cbr>112 Nutritional Supplements and/or Services\u003Cbr>410 Observation\u003Cbr>997 Ofce Visit/Consult | 794 Outpatient Services\u003Cbr>171 Outpatient Surgery\u003Cbr>202 Pain Management\u003Cbr>650 Radiation Therapy\u003Cbr>201 Sleep Study\u003Cbr>472 Stereotactic Radiosurgery\u003Cbr>790 Occupational Therapy\u003Cbr>101 Physical Therapy\u003Cbr>701 Speech Therapy\u003Cbr>993 Transplant Evaluation\u003Cbr>209 Transplant Surgery\u003Cbr>724 Transportation | \u003Cbr>\u003Cbr>\u003Cbr>Behavioral Health\u003Cbr>523 BH Transportation\u003Cbr>515 BH Electroconvulsive Therapy\u003Cbr>516 BH Intensive Outpatient Therapy\u003Cbr>521 BH Psychological Testing\u003Cbr>520 BH Professional Fees\u003Cbr>522 BH Psychiatric Evaluation\u003Cbr>519 BH Outpatient Therapy\u003Cbr>DME\u003Cbr>417 Rental\u003Cbr>120 Purchase\u003Cbr>$\u003Cbr>(Purchase Price)\u003Cbr>Select from the following for BH Outpatient Therapy: BH Residential Facility (BHRF)\u003Cbr>Adult BH Therapeutic Home (ABHTH)\u003Cbr>Therapeutic Foster Care (TFC) |\n\nALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED.  \nCOPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION.  \nDisclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Beneft and medically necessary with prior authorization as per Plan policy and procedures.  \nConfdentiality: The information contained in this transmission is confdential and may be protected under the Health Insurance Portability and Accountability Act of 1996. If you are not the Rev. 01 14 2021  \nintended recipient any use, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and destroy this document. XZ-PAF-1126","cbCaimTxbL4LN7YZ","https://ap.wps.com/l/cbCaimTxbL4LN7YZ","pdf",771735,"English","# AUTHORIZATION FORM\n## Request Type (Standard/Expedited)\n## Member Information\n## Requesting Provider Information\n## Servicing Provider / Facility Information\n## Authorization Request Details\n## Outpatient Service Type Selection\n## Behavioral Health & DME Options\n## Required Fields, Disclaimers","[{\"question\":\"What information is required to submit a Medicaid authorization request?\",\"answer\":\"The form requires member details, requesting and servicing provider/facility information, primary and additional procedure codes and modifiers, service dates, diagnosis codes (ICD-10), and total units/visits/days, with required fields fully completed.\"},{\"question\":\"How do standard and expedited requests differ?\",\"answer\":\"Standard requests follow determination within 14 calendar days after receiving all necessary information. Expedited requests require certification that the request is urgent and medically necessary; urgent (not life threatening) determinations target within 72 hours to avoid complications or severe pain.\"},{\"question\":\"What happens if supporting clinical information is missing or required fields are incomplete?\",\"answer\":\"Incomplete forms will be rejected. Lack of clinical information may result in delayed determination.\"}]","AUTHORIZATION FORM - Request for additional units | PDF",1789632448]