Medicaid Outpatient Authorization Form - Existing Authorization - Rev. 01 2019 - AR-PAF-5856

Sep 17, 2026

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Authorization fax form for Medicaid outpatient services, covering existing authorizations and required member, provider, and request details. Includes standard and urgent request certification rules, required supporting clinical documentation, and deadlines for determination (within five calendar days for standard; within 72 hours for urgent, when medically necessary and non-life-threatening). Requires complete entry of procedure codes, diagnosis ICD-10 codes, admission/start and end/discharge dates, service type selection, and total units/visits/days, with confidentiality and HIPAA-related usage restrictions.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

OUTPATIENT MEDICAID AUTHORIZATION FORM

Member Information

Requesting Provider Information

Servicing Provider/Facility Information

Authorization Request

Complete and Fax Medical requests to: 833-249-2342 Complete and Fax Behavioral requests to: 833-632-6934 OUTPATIENT MEDICAID AUTHORIZATION FORM Existing Authorization | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | Units | | | | | | --- | --- | --- | --- | Standard requests-Determination within 5 calendar days of receipt of request. Urgent requests- I certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within 72 hours to avoid complications and unnecessary suffering or severe pain. * INDICATES REQUIRED FIELD ~~ ~~ MEMBER INFORMATION *Medicaid/Member ID | | | | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | REQUESTING PROVIDER INFORMATION Last Name, First *Date of Birth (MMDDYYYY) | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | | | | | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | *5856* *Requesting NPI *Requesting TIN Requesting Provider Contact Name Requesting Provider Name Phone *Fax SERVICING PROVIDER / FACILITY INFORMATION Same as Requesting Provider *Servicing NPI *Servicing TIN Servicing Provider Contact Name Servicing Provider/Facility Name Phone Fax AUTHORIZATION REQUEST *Primary Procedure Code (CPT/HCPCS) (Modifier) Additional Procedure Code | | | | | | | --- | --- | --- | --- | --- | | | | | --- | --- | Additional Procedure Code | | | | | | | --- | --- | --- | --- | --- | | | | | --- | --- | (CPT/HCPCS) (Modifier) Additional Procedure Code | | | | | | | --- | --- | --- | --- | --- | | | | | --- | --- | *Start Date OR Admission Date | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | (MMDDYYYY) End Date OR Discharge Date | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | *Diagnosis Code (ICD-10) Total Units/Visits/Days | | | | | | --- | --- | --- | --- | (CPT/HCPCS) (Modifier) (CPT/HCPCS) (Modifier) (MMDDYYYY) | *OUTPATIENT SERVICE TYPE (Enter the Service type number in the boxes) | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | | 422 Biopharmacy
712 Cochlear Implants & Surgery
299 Drug Testing
922 Experimental and Investigational Services
205 Genetic Testing & Counseling
249 Home Health
390 Hospice Services
290 Hyperbaric Oxygen Therapy
141 Imaging
112 Nutritional Supplements and/or Services | 790 Occupational Therapy
794 Outpatient Services
171 Outpatient Surgery
202 Pain Management
101 Physical Therapy
201 Sleep Study
701 Speech Therapy
472 Stereotactic Radiosurgery
993 Transplant Evaluation
209 Transplant Surgery
724 Transportation
650 Radiation Therapy | Behavioral Health
533 BH Applied Behavioral Analysis
512 BH Community Based Services
514 BH Day Treatment | | DME
417 Rental
120 Purchase | | | | (Purchase Price) | | | | 515 BH Electroconvulsive Therapy
516 BH Intensive Outpatient Therapy
510 BH Medical Management
518 BH Mental Health /Chemical Dependency Observation
519 BH Outpatient Therapy
530 BH PHP
520 BH Professional Fees
521 BH Psychological Testing | | | | | | | ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED. COPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION. Disclaimer: 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. Confidentiality: The information conta

FAQs

What information must be completed on the outpatient Medicaid authorization fax form?

All required fields must be filled in, including member identifiers, provider details, primary and additional procedure codes (CPT/HCPCS), diagnosis codes (ICD-10), start and end/admission and discharge dates, service type, and total units/visits/days.

What are the determination timelines for standard versus urgent requests?

Standard requests require determination within 5 calendar days of receipt. Urgent requests require certification that the request is medically necessary to treat an injury, illness, or condition within 72 hours to avoid complications and severe pain.

Are clinical supporting documents required and what happens if they are missing?

Copies of all supporting clinical information are required. Lack of clinical information may result in delayed determination.

Sep 17, 2026

Upload by Adam