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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.",{"@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/outpatient-medicaid-authorization-form-form-for-additional-units-requests/287540/",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/outpatient-medicaid-authorization-form-form-for-additional-units-requests/287540.png","ImageObject",442,249,{"name":88,"@type":89},"Stanley","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-26","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 is required to submit the outpatient Medicaid authorization form?","Question",{"text":108,"@type":109},"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.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"When can an urgent request be submitted?",{"text":113,"@type":109},"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.",{"name":115,"@type":106,"acceptedAnswer":116},"Does an approved authorization guarantee payment?",{"text":117,"@type":109},"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.","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},287540,1790262295,{"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},2336477405376,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","OUTPATIENT MEDICAID AUTHORIZATION FORM  \n 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  \nComplete Behavioral Health  \nand Fax to: 1-855-286-1811  \nRequests: FAX 833-405-3827  \nUrgent requests-Please Call 1-855-694-4663. *Urgent requests are made when the member or his/her physician believes that waiting  \nfor a decision under the standard timeframe could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy.  \nALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED. COPIES OF ALL SUPPORTING INFORMATION  \n*INDICATES REQUIRED FIELD  ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION OR DENIAL.   \nMEMBER INFORMATION  \n*Medicaid/Member ID  \nLast Name, First  \n(MMDDYYYY)  \nREQUESTING PROVIDER INFORMATION  \n*0711*  \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(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS)  \nAdditional Procedure Code  \n(CPT/HCPCS)  \n*Start Date OR Admission Date  \n(MMDDYYYY)  \nEnd Date OR Discharge Date  \n(MMDDYYYY)  \n*Diagnosis Code  \n(ICD-10)  \nTotal Units/Visits/Days  \n| *OUTPATIENT SERVICE TYPE (Enter the Service type number in the boxes)  |  |  |  |\n| --- | --- | --- | --- |\n| 412 Auditory Services\u003Cbr>712 Cochlear Implants & Surgery\u003Cbr>299 Drug Testing\u003Cbr>922 Experimental and Investigational Services\u003Cbr>709 Genetic Testing\u003Cbr>249 Home Health\u003Cbr>225 Home Meals\u003Cbr>390 Hospice Services\u003Cbr>410 Observation\u003Cbr>790 Occupational Therapy | 997 Office Visit/Consult\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>724 Transportation\u003Cbr>417 DME-Rental\u003Cbr>| (Purchase Price) | Behavioral Health\u003Cbr>510 BH Medical Management\u003Cbr>512 BH Community Based Services\u003Cbr>513 BH Crisis Psychotherapy\u003Cbr>514 BH Day Treatment\u003Cbr>515 BH Electroconvulsive Therapy\u003Cbr>516 BH Intenstive Outpatient Therapy\u003Cbr>519 BH Outpatient Therapy\u003Cbr>520 BH Professional Fees\u003Cbr>521 BH Psychological Testing\u003Cbr>522 BH Psychiatric Evaluation\u003Cbr>530 BH Partial Hospitilization Program |\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 OR DENIAL.  \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. 10 27 2023 MO-PAF-0711","cbCaivnojZmYIZ0g","https://ap.wps.com/l/cbCaivnojZmYIZ0g","pdf",4016683,"English","# Member Information\n# Requesting Provider Information\n# Servicing Provider / Facility Information\n# Authorization Request\n## Procedure Codes and Dates\n## Diagnosis Code and Total Units\n## Outpatient Service Type Selection","[{\"question\":\"What information is required to submit the outpatient Medicaid authorization form?\",\"answer\":\"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.\"},{\"question\":\"When can an urgent request be submitted?\",\"answer\":\"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.\"},{\"question\":\"Does an approved authorization guarantee payment?\",\"answer\":\"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.\"}]","OUTPATIENT MEDICAID AUTHORIZATION FORM - Form for additional units requests | PDF",1789632453]