[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283854-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283854-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-request-for-additional-units-rev-01-01-2026","OUTPATIENT MEDICAID PRIOR AUTHORIZATION FORM - Request for additional units - Rev. 01 01 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.",{"@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-request-for-additional-units-rev-01-01-2026/283854/",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-request-for-additional-units-rev-01-01-2026/283854.png","ImageObject",442,249,{"name":42,"@type":43},"วิน","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",11,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Where should standard, urgent, buy & bill drug, behavioral health, and transplant requests be faxed?","Question",{"text":63,"@type":64},"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.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What information must be completed for the authorization request?",{"text":68,"@type":64},"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.",{"name":70,"@type":61,"acceptedAnswer":71},"Does an authorization guarantee payment for services?",{"text":72,"@type":64},"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.","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},283854,1790204081,{"code":4,"msg":82,"data":83},"success",[84,88,93,98,103,108,112,117,122],{"id":55,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"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},2336475104736,"https://ap-avatar.wpscdn.com/avatar/22000c4c5e0e5b17e70?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786591360781797222","OUTPATIENT MEDICAID PRIOR 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 833-341-2049 Standard/Urgent Requests: Fax 833-467-1237 Behavioral Health Requests: Fax 833-655-2191  \nTransplant Requests: Fax 833-920-4419  \nUrgent 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.  \n* INDICATES REQUIRED FIELD    \n*Date of Birth  \nMEMBER INFORMATION   \n*Medicaid/Member ID Last Name, First (MMDDYYYY)  \nREQUESTING PROVIDER INFORMATION  \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  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \n*Start Date OR Admission Date  \n(MMDDYYYY)  \nAdditional Procedure Code End Date OR Discharge Date  \n*Diagnosis Code  \n(ICD-10)  \nTotal Units/Visits/Days  \n*6301*  \n(CPT/HCPCS) (Modifier) (CPT/HCPCS) (Modifier) (MMDDYYYY)  \n\n| *OUTPATIENT SERVICE TYPE (Enter the Service type number in the boxes)  |  |  |  |\n| --- | --- | --- | --- |\n| 412 Auditory\u003Cbr>712 Cochlear Implants & Surgery\u003Cbr>922 Experimental and Investigational Services\u003Cbr>205 Genetic Testing & Counseling\u003Cbr>249 Home health\u003Cbr>390 Hospice Services\u003Cbr>290 Hyperbaric Oxygen Therapy\u003Cbr>141 Imaging (NIA, if not managed by Meridian)\u003Cbr>395 Infertility Diagnosis or Treatment\u003Cbr>997 Office Visit/Consult | 794 Outpatient Services (including Speech Therapy)\u003Cbr>171 Outpatient Surgery\u003Cbr>993 Transplant Evaluation\u003Cbr>209 Transplant Surgery\u003Cbr>724 Transportation\u003Cbr>Drugs\u003Cbr>422 Biopharmacy Buy & Bill Drugs\u003Cbr>(Fax Buy & Bill Drug Requests to 833-341-2049) | Behavioral Health\u003Cbr>521 BH Psychological Testing |  |\n|  |  | DME\u003Cbr>417 Rental\u003Cbr>120 Purchase | |\n|  |  | (Purchase Price) |  |\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. 01 01 2026 MI-PAF-6301","cbCaivRLViBbPMGB","https://ap.wps.com/l/cbCaivRLViBbPMGB","pdf",767829,"English","# Outpatient Medicaid Prior Authorization Form\n## Request Details and Determination Timelines\n## Member, Provider, and Facility Information\n## Authorization Request Fields\n## Outpatient Service Type Selection\n## Required Documentation and Disclaimers","[{\"question\":\"Where should standard, urgent, buy \\u0026 bill drug, behavioral health, and transplant requests be faxed?\",\"answer\":\"Standard requests go to 833-467-1237, urgent requests to 833-467-1237, buy \\u0026 bill drug requests to 833-341-2049, behavioral health requests to 833-655-2191, and transplant requests to 833-920-4419.\"},{\"question\":\"What information must be completed for the authorization request?\",\"answer\":\"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.\"},{\"question\":\"Does an authorization guarantee payment for services?\",\"answer\":\"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.\"}]","OUTPATIENT MEDICAID PRIOR AUTHORIZATION FORM - Request for additional units - Rev. 01 01 2026 | PDF",1789620902]