[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-287531-105":53,"doc-detail-287531-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","medicaid-outpatient-authorization-form-existing-authorization-rev-01-2019-ar-paf-5856","Medicaid Outpatient Authorization Form - Existing Authorization - Rev. 01 2019 - AR-PAF-5856","","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.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/medicaid-outpatient-authorization-form-existing-authorization-rev-01-2019-ar-paf-5856/287531/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/medicaid-outpatient-authorization-form-existing-authorization-rev-01-2019-ar-paf-5856/287531.png","ImageObject",442,249,{"name":88,"@type":89},"Adam","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-25","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":47},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information must be completed on the outpatient Medicaid authorization fax form?","Question",{"text":108,"@type":109},"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.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What are the determination timelines for standard versus urgent requests?",{"text":113,"@type":109},"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.",{"name":115,"@type":106,"acceptedAnswer":116},"Are clinical supporting documents required and what happens if they are missing?",{"text":117,"@type":109},"Copies of all supporting clinical information are required. Lack of clinical information may result in delayed determination.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},287531,1790131858,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":47,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},1374404737137,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Complete and Fax Medical requests to: 833-249-2342  \nComplete and Fax Behavioral requests to: 833-632-6934  \nOUTPATIENT MEDICAID  \nAUTHORIZATION FORM  \nExisting Authorization  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nUnits  \n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\n Standard requests-Determination within 5 calendar days of receipt of request.  \n 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.  \n* INDICATES REQUIRED FIELD ~~ ~~  \nMEMBER INFORMATION  \n*Medicaid/Member ID  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nREQUESTING PROVIDER INFORMATION  \nLast Name, First  \n*Date of Birth (MMDDYYYY)  \n\n|  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n\n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\n*5856*  \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\n|  |  |  |  |  |\n| --- | --- | --- | --- | --- |\n\n\n|  |  |\n| --- | --- |\n\nAdditional Procedure Code  \n\n|  |  |  |  |  |\n| --- | --- | --- | --- | --- |\n\n\n|  |  |\n| --- | --- |\n\n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n\n|  |  |  |  |  |\n| --- | --- | --- | --- | --- |\n\n\n|  |  |\n| --- | --- |\n\n*Start Date OR Admission Date  \n\n|  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n\n(MMDDYYYY)  \nEnd Date OR Discharge Date  \n\n|  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n\n*Diagnosis Code  \n(ICD-10)  \nTotal Units/Visits/Days  \n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\n(CPT/HCPCS) (Modifier) (CPT/HCPCS) (Modifier) (MMDDYYYY)  \n\n| *OUTPATIENT SERVICE TYPE (Enter the Service type number in the boxes) |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| 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>141 Imaging\u003Cbr>112 Nutritional Supplements and/or Services | 790 Occupational Therapy\u003Cbr>794 Outpatient Services\u003Cbr>171 Outpatient Surgery\u003Cbr>202 Pain Management\u003Cbr>101 Physical Therapy\u003Cbr>201 Sleep Study\u003Cbr>701 Speech Therapy\u003Cbr>472 Stereotactic Radiosurgery\u003Cbr>993 Transplant Evaluation\u003Cbr>209 Transplant Surgery\u003Cbr>724 Transportation\u003Cbr>650 Radiation Therapy | Behavioral Health\u003Cbr>533 BH Applied Behavioral Analysis\u003Cbr>512 BH Community Based Services\u003Cbr>514 BH Day Treatment |  | DME\u003Cbr>417 Rental\u003Cbr>120 Purchase |  |  | | (Purchase Price) |\n|  |  | 515 BH Electroconvulsive Therapy\u003Cbr>516 BH Intensive Outpatient Therapy\u003Cbr>510 BH Medical Management\u003Cbr>518 BH Mental Health /Chemical Dependency Observation\u003Cbr>519 BH Outpatient Therapy\u003Cbr>530 BH PHP\u003Cbr>520 BH Professional Fees\u003Cbr>521 BH Psychological Testing |  |  |  |  |  |  |\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 conta","cbCaifppoeq5Dxdm","https://ap.wps.com/l/cbCaifppoeq5Dxdm","pdf",94559,"English","# OUTPATIENT MEDICAID AUTHORIZATION FORM\n## Member Information\n## Requesting Provider Information\n## Servicing Provider/Facility Information\n## Authorization Request","[{\"question\":\"What information must be completed on the outpatient Medicaid authorization fax form?\",\"answer\":\"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.\"},{\"question\":\"What are the determination timelines for standard versus urgent requests?\",\"answer\":\"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.\"},{\"question\":\"Are clinical supporting documents required and what happens if they are missing?\",\"answer\":\"Copies of all supporting clinical information are required. Lack of clinical information may result in delayed determination.\"}]","Medicaid Outpatient Authorization Form - Existing Authorization - Rev. 01 2019 - AR-PAF-5856 | PDF",1789632441]