[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283886-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283886-en":126},{"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-prior-authorization-form-elective-request","INPATIENT MEDICAID PRIOR AUTHORIZATION FORM - Elective Request","","Inpatient Medicaid prior authorization form for elective admissions, collecting member identity details, requesting provider and servicing provider/facility information, and a structured authorization request. Includes fields for primary and additional procedure codes (CPT/HCPCS with modifiers), admission or start date, discharge date or length of stay based on medical necessity, and diagnosis codes (ICD-10). Requires completion of all mandatory fields, submission of supporting clinical information, and provides fax submission contacts for standard, behavioral, and neonate requests. Includes eligibility, medical necessity, payment disclaimer, and HIPAA confidentiality notice.",{"@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-prior-authorization-form-elective-request/283886/",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-prior-authorization-form-elective-request/283886.png","ImageObject",442,249,{"name":42,"@type":43},"Elsa","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-22","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",12,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information is required from the member on this inpatient Medicaid prior authorization form?","Question",{"text":63,"@type":64},"The form requires the Medicaid/Member ID, date of birth (MMDDYYYY), and the member’s last name and first name.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Which clinical details must be provided in the authorization request section?",{"text":68,"@type":64},"Submit the primary procedure code (CPT/HCPCS) with modifier, additional procedure codes with modifiers, start date or admission date (MMDDYYYY), discharge date when applicable, and diagnosis codes (ICD-10) including any additional diagnosis codes.",{"name":70,"@type":61,"acceptedAnswer":71},"What happens if the form is incomplete or supporting clinical information is missing?",{"text":72,"@type":64},"Incomplete forms are rejected. Lack of clinical information may result in a delayed determination.","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},283886,1789965872,{"code":4,"msg":82,"data":83},"success",[84,89,93,98,103,108,112,117,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":4},137455077381,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","INPATIENT MEDICAID PRIOR AUTHORIZATION FORM  \n Elective Request  \nComplete and Fax to: 1-866-532-8834  \nBehavioral Fax to: 1-844-263-1379  \nNeonate Fax to: 1-866-532-8850  \nUrgent Request- I certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within 48 hours to avoid complications and unnecessary suffering or severe pain.  \n* Indicates Required Field ~~ ~~  \nMEMBER INFORMATION  \n* Medicaid/Member ID  \n* Date of Birth  \n(MMDDYYYY)  \nLast Name, First  \nREQUESTING PROVIDER INFORMATION  \n*0677*  \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 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)  \nDischarge Date (if applicable) otherwise  \nLength of Stay will be based on Medical Necessity  \n(MMDDYYYY)  \n* Diagnosis Code  \n(ICD-10)  \nAdditional Diagnosis Code  \n(ICD-10)  \n\n| *INPATIENT SERVICE TYPE (Enter the Service type number in the boxes)  |  |  |\n| --- | --- | --- |\n| 490 Boarder Baby\u003Cbr>779 C-Section\u003Cbr>970 Medical\u003Cbr>300 Neonate\u003Cbr>121 Long Term Acute Care\u003Cbr>427 Rehab | 402 Skilled Nursing Facility\u003Cbr>411 Surgical\u003Cbr>720 Vaginal Delivery\u003Cbr>992 Transplant | Behavioral Health\u003Cbr>528-BH-Chemical Substance Abuse 529-BH-Psychiatric Admission 531-BH-Eating Disorders\u003Cbr>532-BH-Crisis Stabilization Unit 535-BH-Residential Treatment Substance Use 536-BH-Res Treatment-Mental Health |\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 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. 08 07 2023  \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. GA-PAF-0677  \nPSHP_092523_0565","cbCaibGLw1f8i4eH","https://ap.wps.com/l/cbCaibGLw1f8i4eH","pdf",805056,"English","# Member Information\n# Requesting Provider Information\n# Servicing Provider / Facility Information\n# Authorization Request\n## Inpatient Service Type\n# Submission Requirements and Disclaimers","[{\"question\":\"What information is required from the member on this inpatient Medicaid prior authorization form?\",\"answer\":\"The form requires the Medicaid/Member ID, date of birth (MMDDYYYY), and the member’s last name and first name.\"},{\"question\":\"Which clinical details must be provided in the authorization request section?\",\"answer\":\"Submit the primary procedure code (CPT/HCPCS) with modifier, additional procedure codes with modifiers, start date or admission date (MMDDYYYY), discharge date when applicable, and diagnosis codes (ICD-10) including any additional diagnosis codes.\"},{\"question\":\"What happens if the form is incomplete or supporting clinical information is missing?\",\"answer\":\"Incomplete forms are rejected. Lack of clinical information may result in a delayed determination.\"}]","INPATIENT MEDICAID PRIOR AUTHORIZATION FORM - Elective Request | PDF",1789621369]