[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-287533-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-287533-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","outpatient-medicaid-authorization-form-request-for-additional-units","OUTPATIENT MEDICAID AUTHORIZATION FORM - Request for additional units","","Outpatient Medicaid Authorization Form for requesting additional service units under existing authorization. It specifies standard processing timelines, contact and fax numbers for different request types (Buy & Bill drugs, Transplant, and DME/HH), and criteria for urgent requests. The form collects required member and provider information, dates of birth, Medicaid/member ID, NPI and TIN for requesting and servicing providers, and an outpatient service type number selection. It also highlights compliance requirements, required supporting clinical documentation, and confidentiality and payment disclaimer statements.",{"@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/outpatient-medicaid-authorization-form-request-for-additional-units/287533/",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/outpatient-medicaid-authorization-form-request-for-additional-units/287533.png","ImageObject",442,249,{"name":42,"@type":43},"Gelato","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-25","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 requests processed for additional outpatient units?","Question",{"text":63,"@type":64},"Standard requests require determination within 7 calendar days of receipt of the request.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"When is a request considered urgent on this form?",{"text":68,"@type":64},"A request is urgent when the member or their physician believes waiting for a decision under the standard timeframe could seriously jeopardize life, health, or the ability to regain maximum function.",{"name":70,"@type":61,"acceptedAnswer":71},"What happens if required fields or supporting clinical information are missing?",{"text":72,"@type":64},"Incomplete forms are rejected, and lack of clinical information may result in delayed determination. All required fields must be filled and all supporting clinical information copies must be included.","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},287533,1790204961,{"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":139,"read_time":4},19241457091524,"https://us-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","OUTPATIENT MEDICAID AUTHORIZATION FORM  \n Request for additional units. Existing Authorization  Units Standard requests-Determination within 7 calendar days of receipt of request.  \nBuy & Bill Drug Requests Fax to: 833-823-0001 Complete and Fax to: 866-796-0526  \nTransplant Request Fax to: 833-550-1338 DME/HH Fax to: (Medicaid) 866-534-5978  \n(LTC) 855-266-5275  \nUrgent requests-Please call 1-844-477-8313. *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.  \n* INDICATES REQUIRED FIELD    \n* Date of Birth  \nMEMBER INFORMATION  \n* Medicaid/Member ID  \nREQUESTING PROVIDER INFORMATION  \n* Requesting NPI * Requesting TIN  \nLast Name, First (MMDDYYYY)  \nRequesting Provider Contact Name  \n*0675*  \nRequesting Provider Name Phone * Fax  \nSERVICING PROVIDER / FACILITY INFORMATION  \n  Same as Requesting Provider  \n*Servicing NPI *Servicing TIN Servicing Provider Contact Name  \n| *OUTPATIENT SERVICE TYPE\u003Cbr>292 Cardiac Rehab\u003Cbr>299 Drug Testing\u003Cbr>205 Genetic Testing & Counseling\u003Cbr>249 Home Health\u003Cbr>225 Home Meals\u003Cbr>390 Hospice Services\u003Cbr>112 Nutritional Supplements\u003Cbr>410 Observation | (Enter the Service type number in the boxes)  |  |\n| --- | --- | --- |\n|  | 997 Ofce Visit/Consult\u003Cbr>794 Outpatient Services\u003Cbr>171 Outpatient Surgery\u003Cbr>202 Pain Management\u003Cbr>427 Rehab (PT, OT, ST)\u003Cbr>201 Sleep Study\u003Cbr>993 Transplant Evaluation\u003Cbr>209 Transplant Surgery\u003Cbr>724 Transportation | Behavioral Health DME\u003Cbr>512 BH Community Based Services 417 DME-Rental \u003Cbr>(Purchase Price)\u003Cbr>515 BH Electroconvulsive Therapy 120 DME-Purchase\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 Drugs\u003Cbr>520 BH Professional Fees 422 Biopharmacy Buy & Bill Drugs\u003Cbr>522 BH Psychiatric Evaluation (Fax Buy & Bill Drug Requests to 1-833-823-0001) |\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 Beneft and medically necessary with prior authorization as per Plan policy and procedures.  \nConfdentiality: The information contained in this transmission is confdential and may be protected under the Health Insurance Portability and Accountability Act of 1996. If you are not the Rev. 03 25 2021  \nintended 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. FL-PAF-0675","cbCaitqkSklStZNC","https://ap.wps.com/l/cbCaitqkSklStZNC","pdf",742192,"English","# Form purpose and requests\n## Timelines and urgent request criteria\n## Fax numbers by request type\n# Required information\n## Member information\n## Requesting provider information\n## Servicing provider and facility information\n# Outpatient service type selection\n## Service type number list\n# Submission requirements and disclaimers","[{\"question\":\"How are standard requests processed for additional outpatient units?\",\"answer\":\"Standard requests require determination within 7 calendar days of receipt of the request.\"},{\"question\":\"When is a request considered urgent on this form?\",\"answer\":\"A request is urgent when the member or their physician believes waiting for a decision under the standard timeframe could seriously jeopardize life, health, or the ability to regain maximum function.\"},{\"question\":\"What happens if required fields or supporting clinical information are missing?\",\"answer\":\"Incomplete forms are rejected, and lack of clinical information may result in delayed determination. All required fields must be filled and all supporting clinical information copies must be included.\"}]","OUTPATIENT MEDICAID AUTHORIZATION FORM - Request for additional units | PDF",1789632441]