[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-287526-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-287526-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","inpatient-medicaid-authorization-form-fax-submission-instructions","INPATIENT MEDICAID AUTHORIZATION FORM - Fax Submission Instructions","","INPATIENT MEDICAID AUTHORIZATION FORM for requesting inpatient Medicaid authorization, including member identification fields (Medicaid/Member ID, name, date of birth), requesting provider details (NPI, TIN, contact, phone, fax), and servicing provider/facility information. The form collects authorization request data such as primary and additional procedure codes (CPT/HCPCS with modifiers), start/admission and discharge dates, diagnosis codes (ICD-10), and inpatient service type selection with behavioral health options. It states all required fields must be completed, supporting clinical copies are required, and includes billing/payment disclaimer, eligibility and medical necessity requirements, and confidentiality notice. Fax numbers are provided for completion and records submission.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/inpatient-medicaid-authorization-form-fax-submission-instructions/287526/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/inpatient-medicaid-authorization-form-fax-submission-instructions/287526.png","ImageObject",442,249,{"name":42,"@type":43},"Cart","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-27","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",6,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information must be completed on the form to avoid rejection?","Question",{"text":63,"@type":64},"All required fields must be filled in. Incomplete forms will be rejected, and copies of all supporting clinical information are required.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Which dates are required for the inpatient authorization request?",{"text":68,"@type":64},"The form requests a start date or admission date (MMDDYYYY) and a discharge date when applicable (MMDDYYYY).",{"name":70,"@type":61,"acceptedAnswer":71},"Does submission of this authorization form guarantee payment?",{"text":72,"@type":64},"No. The form states an authorization is not a guarantee of payment, and services must be covered, medically necessary, and subject to prior authorization per plan policy.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},287526,1789632435,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":80,"read_time":4},18829141979164,"https://eur-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","INPATIENT MEDICAID AUTHORIZATION FORM  \nComplete and Fax to: 877-650-6942  \nFax Medical Records to: 866-683-5632 Behavioral Health Requests/Medical Records: Fax 800-732-7562  \nCoordination of Care  \n* Indicates Required Field ~~ ~~  \nMEMBER INFORMATION  \n* Medicaid/Member ID  \n* Last Name, First  \n* Date of Birth  \n(MMDDYYYY)  \nREQUESTING PROVIDER INFORMATION  \n* Requesting NPI * Requesting TIN Requesting Provider Contact Name  \n*5868*  \n* Requesting Provider Name Phone * Fax  \nSERVICING PROVIDER / FACILITY INFORMATION  \n Same as Requesting Provider  \n*Servicing NPI *Servicing TIN Servicing Provider Contact Name  \n*Servicing Provider/Facility Name Phone *Fax  \nAUTHORIZATION REQUEST  \n*Primary Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \n*Start Date OR Admission Date  \n(MMDDYYYY)  \n*Discharge Date (if applicable)  \n(MMDDYYYY)  \n* Diagnosis Code  \n(ICD-10)  \nAdditional Diagnosis Code  \n(ICD-10)  \n*INPATIENT SERVICE TYPE * (Enter the Service type number in the boxes)  \nCheck Box for Inpatient Elective Service BEHAVIORAL HEALTH  \n490 Boarder Baby 535 BH Residential Treatment-Substance Use  \n779 C-Section 536 BH Residential Treatment-Mental Health  \n970 Medical 528 BH Chemical Substance Abuse  \n300 Neonate 532 BH Crisis Stabilization Unit  \n414 Premature/False Labor 531 BH Eating Disorders  \n427 Rehab 529 BH Psychiatric Admission  \n492 Sub-Acute  \n411 Surgical  \n992 Transplant  \n720 Vaginal Delivery  \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 Benefit and medically necessary with prior authorization as per Plan policy and procedures.  \nConfidentiality: The information contained in this transmission is confidential and may be protected under the Health Insurance Portability and Accountability Act of 1996. If you are not Rev.04.02.2021  \nthe intended 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. TX-PAF-5868","cbCaioUl4xDpjisR","https://ap.wps.com/l/cbCaioUl4xDpjisR","pdf",141493,"English","# Member Information\n# Requesting Provider Information\n# Servicing Provider / Facility Information\n# Authorization Request\n## Procedure Codes and Diagnosis Codes\n## Inpatient Service Type\n# Important Notices","[{\"question\":\"What information must be completed on the form to avoid rejection?\",\"answer\":\"All required fields must be filled in. Incomplete forms will be rejected, and copies of all supporting clinical information are required.\"},{\"question\":\"Which dates are required for the inpatient authorization request?\",\"answer\":\"The form requests a start date or admission date (MMDDYYYY) and a discharge date when applicable (MMDDYYYY).\"},{\"question\":\"Does submission of this authorization form guarantee payment?\",\"answer\":\"No. The form states an authorization is not a guarantee of payment, and services must be covered, medically necessary, and subject to prior authorization per plan policy.\"}]","INPATIENT MEDICAID AUTHORIZATION FORM - Fax Submission Instructions | PDF"]