[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283885-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283885-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-prior-authorization-form-062025","Outpatient Medicaid Prior Authorization Form - 062025","","Outpatient Medicaid prior authorization form for requesting coverage of medically necessary outpatient services. Collects member details, requesting and servicing provider/facility information, primary and additional procedure codes, modifiers, diagnosis code, and admission/start and end/discharge dates, along with total units/visits/days and an outpatient service type selection. Includes standard and expedited request timing rules, fax numbers for behavioral health, transplant, and buy & bill drugs, and required clinical documentation guidance. Notes that authorization is not a payment guarantee and includes HIPAA confidentiality terms.",{"@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-prior-authorization-form-062025/283885/",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-prior-authorization-form-062025/283885.png","ImageObject",442,249,{"name":42,"@type":43},"Jasmine","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-27","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",12,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information is required to submit this outpatient Medicaid prior authorization request?","Question",{"text":63,"@type":64},"The form requires member information, requesting and servicing provider details, primary and additional procedure codes with modifiers, diagnosis code, start/admission and end/discharge dates, and total units/visits/days, plus a selected outpatient service type.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How do standard and expedited request timelines work?",{"text":68,"@type":64},"Standard requests require determination within 3 calendar days and/or 2 business days after receiving all necessary information. Expedited requests require certification that using the standard timeframe could seriously jeopardize the member’s life, health, or ability to attain, maintain, or regain maximum function.",{"name":70,"@type":61,"acceptedAnswer":71},"Is prior authorization a guarantee of payment?",{"text":72,"@type":64},"No. The form states that authorization is not a guarantee of payment, and the member must be eligible when services are rendered.","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},283885,1790945812,{"code":4,"msg":82,"data":83},"success",[84,89,93,98,103,108,112,117,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"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":109,"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},2336478487870,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","Standard Requests: Fax 877-650-6943  \nOUTPATIENT MEDICAID  \nBehavioral Health Requests: Fax 833-840-0479  \nPRIOR AUTHORIZATION  \nFORM  \nTransplant Requests: Fax 833-589-1239 Buy & Bill Drugs: Fax 833-611-2385  \nRequest for additional units. Existing Authorization  Units  Standard requests-Determination within 3 calendar days and/or 2 business days of receiving all necessary information  \nExpedited requests- I certify that following the standard authorization decision time frame could seriously jeopardize the member’s life, health, or ability to attain, maintain, or regain maximum function.  \n* INDICATES REQUIRED FIELD    \nDate of Birth*  \nMEMBER INFORMATION   \nMedicaid/Member ID* Last Name, First (MMDDYYYY)  \nREQUESTING PROVIDER INFORMATION  \nRequesting NPI* Requesting TIN* Requesting Provider Contact Name  \n*  \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*  \nStart Date OR Admission Date  \nDiagnosis Code*  \n*0618*  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \n(MMDDYYYY)  \nEnd Date OR Discharge Date*  \n(MMDDYYYY)  \n(ICD-10)  \nTotal Units/Visits/Days  \n| OUTPATIENT SERVICE TYPE* (Enter the Service type number in the boxes)  |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| 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\u003Cbr>533 BH Applied Behavioral Analysis | 412 Auditory Services\u003Cbr>422 Biopharmacy\u003Cbr>401 Cardiac/Pulmonary Rehab\u003Cbr>712 Cochlear Implants & Surgery\u003Cbr>299 Drug Testing\u003Cbr>205 Genetic Testing & Counseling\u003Cbr>249 Home Health\u003Cbr>390 Hospice Services\u003Cbr>201 Sleep Study\u003Cbr>701 Speech Therapy\u003Cbr>472 Stereotactic Radiosurgery\u003Cbr>181 Swing Bed\u003Cbr>724 Transportation | 290 Hyperbaric Oxygen Therapy\u003Cbr>729 Neuropsych Testing\u003Cbr>410 Observation\u003Cbr>790 Occupational Therapy\u003Cbr>210 Orthotics\u003Cbr>794 Outpatient Services\u003Cbr>171 Outpatient Surgery\u003Cbr>202 Pain Management\u003Cbr>650 Radiation Therapy\u003Cbr>101 Physical Therapy\u003Cbr>147 Prosthetics\u003Cbr>993 Transplant Evaluation\u003Cbr>209 Transplant Surgery | DME |  |\n|  |  |  | 417 Rental\u003Cbr>120 Purchase | |\n|  |  |  | Outpatient Services Example:\u003Cbr>-Skin Debridement/Wound Care\u003Cbr>Outpatient Surgery Examples:\u003Cbr>-Hysterectomy\u003Cbr>-Mammoplasty\u003Cbr>-Rhino/Septoplasty |  |\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 11 05 2024 MS-PAF-0618","cbCaipBkLoMOH7uN","https://ap.wps.com/l/cbCaipBkLoMOH7uN","pdf",1218645,"English","# Authorization Request\n## Member Information\n## Requesting Provider Information\n## Servicing Provider / Facility Information\n## Authorization Details\n## Outpatient Service Type\n## Required Documentation and Disclaimers","[{\"question\":\"What information is required to submit this outpatient Medicaid prior authorization request?\",\"answer\":\"The form requires member information, requesting and servicing provider details, primary and additional procedure codes with modifiers, diagnosis code, start/admission and end/discharge dates, and total units/visits/days, plus a selected outpatient service type.\"},{\"question\":\"How do standard and expedited request timelines work?\",\"answer\":\"Standard requests require determination within 3 calendar days and/or 2 business days after receiving all necessary information. Expedited requests require certification that using the standard timeframe could seriously jeopardize the member’s life, health, or ability to attain, maintain, or regain maximum function.\"},{\"question\":\"Is prior authorization a guarantee of payment?\",\"answer\":\"No. The form states that authorization is not a guarantee of payment, and the member must be eligible when services are rendered.\"}]","Outpatient Medicaid Prior Authorization Form - 062025 | PDF",1789621368]