[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-288178-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-288178-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","medicare-outpatient-prior-authorization-request-form","Medicare Outpatient Prior Authorization Request Form","","Medicare outpatient prior authorization request form for standard and expedited determinations. Includes instructions for Fax requests to designated numbers, and a separate process for Part B drug requests, with clear timeframes and eligibility criteria. Collects member demographics and identification, requesting and servicing provider details, procedure codes (primary, additional with modifiers), diagnosis codes, admission/start and end/discharge dates, and total units/visits/days. Requires required fields to be complete and submission of supporting clinical information. Authorization is not a payment guarantee.",{"@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/medicare-outpatient-prior-authorization-request-form/288178/",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/medicare-outpatient-prior-authorization-request-form/288178.png","ImageObject",442,249,{"name":42,"@type":43},"Oliver","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",5,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"How are standard versus expedited requests submitted and determined?","Question",{"text":63,"@type":64},"Standard requests are faxed to 1-877-687-1183, and determinations are made as expeditiously as the enrollee’s condition requires but no later than 14 calendar days after receipt. Expedited requests are made by calling 1-877-935-8024 when waiting under standard timelines could seriously jeopardize life, health, or ability to regain maximum function.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Where should Part B drug requests be faxed?",{"text":68,"@type":64},"Part B drug requests should be faxed to 1-844-960-1787.",{"name":70,"@type":61,"acceptedAnswer":71},"What information must be provided to avoid rejection or delays?",{"text":72,"@type":64},"All required fields must be completed, as incomplete forms are rejected. Copies of all supporting clinical information are required because lack of clinical information may result in 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},288178,1789633202,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,122],{"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":55,"slug":121},21,"Paper Templates","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":110,"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":80,"read_time":4},8796095461610,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","OUTPATIENT MEDICARE AUTHORIZATION FORM  \nStandard Requests: Fax to 1-877-687-1183  \nPart B Drug requests: Fax to 1-844-960-1787  \nRequest for additional units. Existing Authorization Units  \nFor Standard requests, complete this form and FAX to 1-877-687-1183. Determination made as expeditiously as the enrollee’s health condition requires, but no later than 14 calendar days after receipt of request.  \nFor Expedited requests, please CALL 1-877-935-8024. Expedited requests are made when the enrollee or his/her physician believes that waiting for a decision under the standard  \ntimeframe could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy.  \nFor Part B Drug requests please fax to 1-844-960-1787.  \n* INDICATES REQUIRED FIELD   \nDate of Birth*  \nMEMBER INFORMATION  \nMember ID* Last Name, First (MMDDYYYY)  \nREQUESTING PROVIDER INFORMATION  \nRequesting NPI* Requesting TIN* Requesting Provider Contact Name  \nRequesting Provider Name Phone Fax*  \nSERVICING PROVIDER / FACILITY INFORMATION  \n Same as Requesting Provider  \nServicing NPI* Servicing TIN* Servicing Provider Contact Name  \nServicing Provider/Facility Name Phone Fax  \nAUTHORIZATION REQUEST  \n*  \nPrimary Procedure Code  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier) (CPT/HCPCS) (Modifier)  \n*  \nStart Date OR Admission Date  \n(MMDDYYYY)  \nEnd Date OR Discharge Date  \n(MMDDYYYY)  \nDiagnosis Code*  \n(ICD-10)  \nTotal Units/Visits/Days  \n*0763*  \n\n| OUTPATIENT SERVICE TYPE* (Enter the Service type number in the boxes) |  |  |  |\n| --- | --- | --- | --- |\n| 712 Cochlear Implants & Surgery\u003Cbr>299 Drug Testing\u003Cbr>922 Experimentatl & Investigational Services\u003Cbr>205 Genetic Testing & Counseling\u003Cbr>249 Home Health\u003Cbr>290 Hyperbaric Oxygen Therapy\u003Cbr>729 Imaging Services\u003Cbr>395 Infertility Diagnosis or Treatment\u003Cbr>729 Neuropsychological Testing\u003Cbr>410 Observation\u003Cbr>997 Office Visit/Consult\u003Cbr>794 Outpatient Services\u003Cbr>422 Biopharmacy (Please fax to 1-844-960-1787) | 171 Outpatient Surgery\u003Cbr>202 Pain Management\u003Cbr>201 Sleep Study\u003Cbr>993 Transplant Evaluation\u003Cbr>209 Transplant Surgery\u003Cbr>724 Transportation | Therapy\u003Cbr>790 Occupational\u003Cbr>101 Physical\u003Cbr>650 Radiation\u003Cbr>701 Speech\u003Cbr>212 Evaluation | BEHAVIORAL HEALTH\u003Cbr>512 BH Community Based Services\u003Cbr>513 BH Crisis Psychotherapy\u003Cbr>514 BH Day Treatment\u003Cbr>515 BH Electroconvulsive Therapy\u003Cbr>510 BH Medical Management\u003Cbr>518 BH Mental Health /Chemical\u003Cbr>519 BH Outpatient Therapy\u003Cbr>530 BH PHP\u003Cbr>520 BH Professional Fees\u003Cbr>521 BH Psychological Testing\u003Cbr>522 BH Psychiatric Evaluation |\n|  | DME (Orthotics and Prosthetics)\u003Cbr>417 Rental\u003Cbr>120 Purchase\u003Cbr>(Purchase Price)\u003Cbr>Outpatient Services Example: Skin Debridement/wound care\u003Cbr>Home Health Example: Skilled Nursing Visits |  |  |\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 the 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.  \nRev. 12 24 2019 WI-PAF-0763","cbCaihujhTGSbXx4","https://ap.wps.com/l/cbCaihujhTGSbXx4","pdf",263476,"English","# Member Information\n# Requesting Provider Information\n# Servicing Provider / Facility Information\n# Authorization Request\n## Procedure Codes (CPT/HCPCS)\n## Dates, Diagnosis, and Total Units/Visits/Days","[{\"question\":\"How are standard versus expedited requests submitted and determined?\",\"answer\":\"Standard requests are faxed to 1-877-687-1183, and determinations are made as expeditiously as the enrollee’s condition requires but no later than 14 calendar days after receipt. Expedited requests are made by calling 1-877-935-8024 when waiting under standard timelines could seriously jeopardize life, health, or ability to regain maximum function.\"},{\"question\":\"Where should Part B drug requests be faxed?\",\"answer\":\"Part B drug requests should be faxed to 1-844-960-1787.\"},{\"question\":\"What information must be provided to avoid rejection or delays?\",\"answer\":\"All required fields must be completed, as incomplete forms are rejected. Copies of all supporting clinical information are required because lack of clinical information may result in delayed determination.\"}]","Medicare Outpatient Prior Authorization Request Form | PDF"]