OUTPATIENT MEDICAID AUTHORIZATION FORM - Form for additional units requests

Sep 17, 2026

Upload by Stanley

OUTPATIENT MEDICAID AUTHORIZATION FORM used to request additional units for outpatient services under Medicaid. Collects member information, requesting provider and servicing provider/facility details, primary and additional procedure codes (CPT/HCPCS with modifiers), diagnosis code (ICD-10), and start/end dates. Requires total units/visits/days and an outpatient service type selection number. Includes behavioral health options, urgent vs standard request timing guidance, and mandates submission of all required clinical supporting information to avoid delays or denial, with a payment and eligibility disclaimer.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Member Information

Requesting Provider Information

Servicing Provider / Facility Information

Authorization Request

Procedure Codes and Dates

Diagnosis Code and Total Units

Outpatient Service Type Selection

OUTPATIENT MEDICAID AUTHORIZATION FORM Request for additional units. Existing Authorization Units Standard requests-Determination within 36 hours or up to 14 days if necessary to receive all pertinent clinical information Complete Behavioral Health and Fax to: 1-855-286-1811 Requests: FAX 833-405-3827 Urgent requests-Please Call 1-855-694-4663. *Urgent requests are made when the member or his/her physician believes that waiting for a decision under the standard timeframe could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy. ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED. COPIES OF ALL SUPPORTING INFORMATION *INDICATES REQUIRED FIELD ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION OR DENIAL. MEMBER INFORMATION *Medicaid/Member ID Last Name, First (MMDDYYYY) REQUESTING PROVIDER INFORMATION *0711* *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 (CPT/HCPCS) (Modifier) Additional Procedure Code (CPT/HCPCS) Additional Procedure Code (CPT/HCPCS) *Start Date OR Admission Date (MMDDYYYY) End Date OR Discharge Date (MMDDYYYY) *Diagnosis Code (ICD-10) Total Units/Visits/Days | *OUTPATIENT SERVICE TYPE (Enter the Service type number in the boxes) | | | | | --- | --- | --- | --- | | 412 Auditory Services
712 Cochlear Implants & Surgery
299 Drug Testing
922 Experimental and Investigational Services
709 Genetic Testing
249 Home Health
225 Home Meals
390 Hospice Services
410 Observation
790 Occupational Therapy | 997 Office Visit/Consult
794 Outpatient Services
171 Outpatient Surgery
202 Pain Management
101 Physical Therapy
201 Sleep Study
701 Speech Therapy
724 Transportation
417 DME-Rental
| (Purchase Price) | Behavioral Health
510 BH Medical Management
512 BH Community Based Services
513 BH Crisis Psychotherapy
514 BH Day Treatment
515 BH Electroconvulsive Therapy
516 BH Intenstive Outpatient Therapy
519 BH Outpatient Therapy
520 BH Professional Fees
521 BH Psychological Testing
522 BH Psychiatric Evaluation
530 BH Partial Hospitilization Program | 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 OR DENIAL. 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 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. Rev. 10 27 2023 MO-PAF-0711

FAQs

What information is required to submit the outpatient Medicaid authorization form?

The form requires member details, provider and facility information, procedure codes (CPT/HCPCS) with modifiers, diagnosis code (ICD-10), start/end dates, and total units/visits/days plus the outpatient service type number.

When can an urgent request be submitted?

An urgent request is appropriate when the member or physician believes waiting for a standard decision could seriously jeopardize life, health, or the ability to regain maximum function.

Does an approved authorization guarantee payment?

No. Authorization is not a guarantee of payment; the member must be eligible when services are rendered and services must be covered and medically necessary under plan policy.

Sep 17, 2026

Upload by Stanley