OUTPATIENT MEDICAID PRIOR AUTHORIZATION FORM - Request for additional units - Rev. 01 01 2026

Sep 17, 2026

Outpatient Medicaid prior authorization form for requesting additional units/visits/days. Includes member information, requesting provider and servicing provider/facility details, and an authorization request section covering primary and additional procedure codes, diagnosis codes (ICD-10), start/admission and end/discharge dates, and total quantities. Provides service type selections and specifies separate fax lines for standard/urgent, buy & bill drugs, behavioral health, and transplant requests. Requires all marked fields, supporting clinical documentation, and notes that authorization is not a payment guarantee; revocation and confidentiality apply.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Outpatient Medicaid Prior Authorization Form

Request Details and Determination Timelines

Member, Provider, and Facility Information

Authorization Request Fields

Outpatient Service Type Selection

Required Documentation and Disclaimers

OUTPATIENT MEDICAID PRIOR AUTHORIZATION FORM Request for additional units. Existing Authorization Units Standard Requests-Determination within 7 calendar days of receipt of request. Buy & Bill Drug Requests: Fax 833-341-2049 Standard/Urgent Requests: Fax 833-467-1237 Behavioral Health Requests: Fax 833-655-2191 Transplant Requests: Fax 833-920-4419 Urgent Requests- I certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within 72 hours to avoid complications and unnecessary suffering or severe pain. * INDICATES REQUIRED FIELD *Date of Birth MEMBER INFORMATION *Medicaid/Member ID Last Name, First (MMDDYYYY) REQUESTING PROVIDER INFORMATION *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 Additional Procedure Code (CPT/HCPCS) (Modifier) *Start Date OR Admission Date (MMDDYYYY) Additional Procedure Code End Date OR Discharge Date *Diagnosis Code (ICD-10) Total Units/Visits/Days *6301* (CPT/HCPCS) (Modifier) (CPT/HCPCS) (Modifier) (MMDDYYYY) | *OUTPATIENT SERVICE TYPE (Enter the Service type number in the boxes) | | | | | --- | --- | --- | --- | | 412 Auditory
712 Cochlear Implants & Surgery
922 Experimental and Investigational Services
205 Genetic Testing & Counseling
249 Home health
390 Hospice Services
290 Hyperbaric Oxygen Therapy
141 Imaging (NIA, if not managed by Meridian)
395 Infertility Diagnosis or Treatment
997 Office Visit/Consult | 794 Outpatient Services (including Speech Therapy)
171 Outpatient Surgery
993 Transplant Evaluation
209 Transplant Surgery
724 Transportation
Drugs
422 Biopharmacy Buy & Bill Drugs
(Fax Buy & Bill Drug Requests to 833-341-2049) | Behavioral Health
521 BH Psychological Testing | | | | | DME
417 Rental
120 Purchase | | | | | (Purchase Price) | | 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. 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. 01 01 2026 MI-PAF-6301

FAQs

Where should standard, urgent, buy & bill drug, behavioral health, and transplant requests be faxed?

Standard requests go to 833-467-1237, urgent requests to 833-467-1237, buy & bill drug requests to 833-341-2049, behavioral health requests to 833-655-2191, and transplant requests to 833-920-4419.

What information must be completed for the authorization request?

Required fields include member demographics/ID, requesting provider NPI and TIN, servicing provider/facility NPI and TIN, primary procedure code (CPT/HCPCS) with modifier(s), diagnosis code (ICD-10), start/admission and end/discharge dates, and totals for units/visits/days, plus any additional procedure codes as applicable.

Does an authorization guarantee payment for services?

No. The form states that an authorization is not a guarantee of payment, and services must be covered, medically necessary, and compliant with plan policies and procedures.

Sep 17, 2026

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