[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-286651-105":53,"doc-detail-286651-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","medical-prior-authorization-form","Medical Prior Authorization Form","","This document provides a standardized medical prior authorization form issued by Priority Health. It is designed for healthcare providers to request authorization for planned surgeries, procedures, or outpatient services. The form requires detailed member information, including Priority Health ID, dates of service, diagnosis and procedure codes, as well as provider and facility identification. It includes sections for contact information and necessary clinical documentation like lab results and imaging, ensuring complete data submission to avoid processing delays. This template is specifically excluded for use in emergent inpatient requests, which require a separate designated form, and emphasizes compliance with federal Medicaid enrollment regulations for those seeking payment.",{"@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/medical-prior-authorization-form/286651/",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/medical-prior-authorization-form/286651.png","ImageObject",442,249,{"name":88,"@type":89},"Mason","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-25","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What types of requests should NOT use this form?","Question",{"text":108,"@type":109},"This form should not be used for emergent inpatient requests, for which a separate Emergent Inpatient Form is provided.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What is required to receive payment from Medicaid programs?",{"text":113,"@type":109},"Federal regulation requires that service providers for a Medicaid beneficiary must enroll in CHAMPS (Community Health Automated Medicaid Processing System).",{"name":115,"@type":106,"acceptedAnswer":116},"What does the 'Expedited' priority selection signify?",{"text":117,"@type":109},"By selecting 'Expedited', the provider attests that the standard processing timeframe could seriously jeopardize the member’s health, life, or ability to regain maximum function.","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},286651,1790299774,{"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":79,"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},5909887256941,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Medical prior authorization form  \nMissing or incomplete information, including required clinical documentation, may result in delays. Don’t use this form for emergent inpatient requests. Instead use our Emergent Inpatient Form.  \nCheck if requesting on behalf of a Cigna-participating provider  \nCheck if your request is a Medicare Pre-Service Organization Determination (PSOD)  \nDate of request:    \nType of service  \nPlanned surgery / procedure  \nInpatient  \nOutpatient / observation  \nPriority  \nStandard  \nOutpatient service  \nExpedited* Retrospective  \n*By checking this box, I attest that applying the standard timeframe could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function.  \nMember information  \n\n| Member last name |  | Member first name |  |\n| --- | --- | --- | --- |\n| Priority Health ID\\# |  | Date of birth |  |\n\n\n| Date(s) of service | From: | To: |  |\n| --- | --- | --- | --- |\n| Diagnosis code(s) |  | Diagnosis |  |\n| Procedure code(s) |  | Procedure |  |\n\nProvider / facility information  \n\n| Provider name |  | Facility name |  |\n| --- | --- | --- | --- |\n| Provider TIN |  | Facility TIN |  |\n| Provider NPI |  | Facility NPI |  |\n| Address |  | Address |  |\n|  |  |  |  |\n\nContact  \n\n| Name |  |  |  |\n| --- | --- | --- | --- |\n| Phone |  | Fax |  |\n\nAdditional information (i.e., H&P, labs, vitals, medication record, imaging)  \nTo receive payment from any Medicaid program, federal regulation requires that those providing services to a Medicaid beneficiary must enroll in CHAMPS (Community Health Automated Medicaid Processing System) to  \nPrint  \n© Priority Health 03/2023","cbCaioL5rAycTAPC","https://ap.wps.com/l/cbCaioL5rAycTAPC","pdf",341446,"English","# Member and Service Information\n## Provider and Facility Details\n## Clinical Documentation and Requirements","[{\"question\":\"What types of requests should NOT use this form?\",\"answer\":\"This form should not be used for emergent inpatient requests, for which a separate Emergent Inpatient Form is provided.\"},{\"question\":\"What is required to receive payment from Medicaid programs?\",\"answer\":\"Federal regulation requires that service providers for a Medicaid beneficiary must enroll in CHAMPS (Community Health Automated Medicaid Processing System).\"},{\"question\":\"What does the 'Expedited' priority selection signify?\",\"answer\":\"By selecting 'Expedited', the provider attests that the standard processing timeframe could seriously jeopardize the member’s health, life, or ability to regain maximum function.\"}]","Medical Prior Authorization Form | PDF",1789631385]