[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283883-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283883-en":127},{"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-rev-10-31-2023","OUTPATIENT MEDICAID PRIOR AUTHORIZATION FORM - Rev. 10 31 2023","","Outpatient Medicaid prior authorization request form for submitting procedure and diagnosis details, provider and facility information, and service type selection across multiple outpatient categories. Includes instructions for standard and urgent determination timelines, required signature requirements for urgent requests, and fields for CPT/HCPCS codes, modifiers, date ranges, and total units or visits. Contains compliance notices on completeness, clinical documentation requirements, confidentiality, HIPAA protections, and a disclaimer that authorization does not guarantee payment.",{"@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-rev-10-31-2023/283883/",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-rev-10-31-2023/283883.png","ImageObject",442,249,{"name":42,"@type":43},"Mack Lee","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",10,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What is the difference between a standard request and an urgent request?","Question",{"text":63,"@type":64},"A standard request is determined within 5 working days of receiving all necessary information, not to exceed 14 calendar days. An urgent request must be certified as medically necessary to treat an injury, illness, or condition within 72 hours to avoid complications and must be signed by the requesting physician to receive priority.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Which fields are required to submit the prior authorization request?",{"text":68,"@type":64},"Required fields are marked with an asterisk and must be fully completed. Incomplete forms are rejected, and all required supporting clinical information must be included to avoid delayed determination.",{"name":70,"@type":61,"acceptedAnswer":71},"Does prior authorization guarantee payment?",{"text":72,"@type":64},"No. The form states that authorization is not a guarantee of payment. The member must be eligible when services are rendered and the services must be covered and medically necessary according to plan policy 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},283883,1791488620,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"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":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":4},1236954509970,"https://us-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","OUTPATIENT MEDICAID PRIOR AUTHORIZATION FORM  \nComplete and Fax: 866-467-1316  \nTransplant: Fax 833-769-1051  \nBehavioral Health Requests: Fax 833-522-2807  \n Request for additional units. Existing Authorization  Units   \n Standard Request-Determination within 5 working days of receiving all necessary information, not to exceed 14 calendar days from receipt.  \nUrgent Request- 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  \nURGENT REQUESTS MUST BE SIGNED BY THE REQUESTING PHYSICIAN TO RECEIVE PRIORITY.  \n*Date of Birth  \nMEMBER INFORMATION  \n*Member ID Last Name, First (MMDDYYYY)  \nORDERING PROVIDER INFORMATION  \n*0741*  \n*Ordering NPI *Ordering TIN Ordering Provider Contact Name  \nOrdering Provider Name Phone *Fax  \nSERVICING PROVIDER / FACILITY INFORMATION  \n  Same as Ordering Provider  \n*Servicing NPI *Servicing TIN Servicing Provider Contact Name  \nServicing Provider/Facility Name Phone Fax  \nAUTHORIZATION REQUEST  \n*Primary Procedure Code  \nAdditional Procedure Code  \n(CPT/HCPCS)  \nAdditional Procedure Code  \n*Start Date OR Admission Date  \n(MMDDYYYY)  \nEnd Date OR Discharge Date  \n*Diagnosis Code  \n(ICD-10)  \nTotal Units/Visits/Days  \n(CPT/HCPCS) (Modifier) (CPT/HCPCS) (Modifier) (MMDDYYYY)  \n\n| *OUTPATIENT SERVICE TYPE | (Enter the Service type number in the box) |  | |  |  |\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 | 422 Biopharmacy\u003Cbr>299 Drug Testing\u003Cbr>709 Genetic Testing & Counseling\u003Cbr>249 Home health\u003Cbr>390 Hospice Services\u003Cbr>141 Imaging\u003Cbr>997 Office Visit/Consult\u003Cbr>794 Outpatient Services\u003Cbr>171 Outpatient Surgery\u003Cbr>202 Pain Management\u003Cbr>470 Personal Care Worker Services\u003Cbr>101 Physical Therapy\u003Cbr>790 Occupational Therapy\u003Cbr>701 Speech Therapy | 107 Respite Care\u003Cbr>201 Sleep Study\u003Cbr>993 Transplant Evaluation\u003Cbr>209 Transplant Surgery\u003Cbr>724 Transportation |  | DME\u003Cbr>417 Rental\u003Cbr>120 Purchase | |\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. 10 31 2023 WI-PAF-0741","cbCaivh3SQyHEQrY","https://ap.wps.com/l/cbCaivh3SQyHEQrY","pdf",1235723,"English","# OUTPATIENT MEDICAID PRIOR AUTHORIZATION FORM\n## Request Timing (Standard and Urgent)\n## Member Information\n## Ordering Provider Information\n## Servicing Provider/Facility Information\n## Authorization Request Details\n## Outpatient Service Type Selection","[{\"question\":\"What is the difference between a standard request and an urgent request?\",\"answer\":\"A standard request is determined within 5 working days of receiving all necessary information, not to exceed 14 calendar days. An urgent request must be certified as medically necessary to treat an injury, illness, or condition within 72 hours to avoid complications and must be signed by the requesting physician to receive priority.\"},{\"question\":\"Which fields are required to submit the prior authorization request?\",\"answer\":\"Required fields are marked with an asterisk and must be fully completed. Incomplete forms are rejected, and all required supporting clinical information must be included to avoid delayed determination.\"},{\"question\":\"Does prior authorization guarantee payment?\",\"answer\":\"No. The form states that authorization is not a guarantee of payment. The member must be eligible when services are rendered and the services must be covered and medically necessary according to plan policy and procedures.\"}]","OUTPATIENT MEDICAID PRIOR AUTHORIZATION FORM - Rev. 10 31 2023 | PDF",1789621363]