[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288194-105":53,"doc-detail-288194-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","outpatient-therapy-services-prior-authorization-request-form-authorization-instructions","Outpatient Therapy Services Prior Authorization Request Form - Authorization Instructions","","Authorization request form for outpatient therapy and related rehabilitation and chiropractic care. Gather member, diagnosis, ICD-10, ordering provider, treating provider, and therapy request details including new or ongoing status and procedure code entries with start/end dates, visits, and frequency. Submit complete, legible information and supporting clinical documentation to support medical necessity; incomplete or unreadable submissions delay processing. Fax to Highmark Health Options and contact utilization management for questions during weekday hours.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/outpatient-therapy-services-prior-authorization-request-form-authorization-instructions/288194/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/outpatient-therapy-services-prior-authorization-request-form-authorization-instructions/288194.png","ImageObject",442,249,{"name":88,"@type":89},"Levi","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-21","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information must be completed on the outpatient therapy prior authorization request form?","Question",{"text":108,"@type":109},"The form requires member details (name, ID, date of birth), diagnosis and ICD-10 code, ordering provider information, treating provider information, and the outpatient therapy request including new or ongoing status and procedure code data with dates, number of visits, and frequency.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Where should the completed form be sent and how is authorization determined?",{"text":113,"@type":109},"Fax the completed form with requested supporting documentation to Highmark Health Options at 1-855-451-6664. Authorization is based on medical necessity.",{"name":115,"@type":106,"acceptedAnswer":116},"What happens if the submission is incomplete or illegible?",{"text":117,"@type":109},"Incomplete information or illegible forms will delay processing. Include clinical documentation such as initial evaluation, current plan of care, physician order, current prescription, and recent progress notes as applicable.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288194,1789987930,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":73,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},7971461740909,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Use this form for all physical, occupational, speech, and feeding therapies, pulmonary and cardiac rehabilitation, and chiropractic care. Complete and fax all requested information below including any supporting documentation as applicable to Highmark Health Options at 1-855-451-6664. Authorization is based on medical necessity. Incomplete information or illegible forms will delay processing.  \nQuestions or concerns? Call Utilization Management at 1-844-325-6251, Monday through Friday, [8 a.m. to 5 p.m](8 a.m. to 5 p.m).  \nDate:    \n\n| Member Information |  |  |  |\n| --- | --- | --- | --- |\n| Member Name | Member ID |  | Date of Birth |\n| Diagnosis |  | ICD-10 Code |  |\n\n\n| Ordering Provider Information |  |\n| --- | --- |\n| Ordering Provider Name | NPI Number |\n| Ordering Provider Practice and Address |  |\n| Provider Phone | Provider Fax |\n\n\n| Treating Provider Information |  |\n| --- | --- |\n| Treating Provider Name | NPI Number |\n| Treating Provider Practice and Address |  |\n| Provider Phone | Provider Fax |\n| Contact Person Completing Form | Contact Phone |\n| Contact Person at Practice | Contact Fax |\n\n\n| Outpatient Therapy Request |  |\n| --- | --- |\n| New Request ☐ Yes ☐ No | Ongoing Request ☐ Yes ☐ No |\n\n\n| Physical Therapy |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Procedure Code | Code Description | Start Date | End Date | Number of Visits | Frequency |\n\n\n| Occupational Therapy |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Procedure Code | Code Description | Start Date | End Date | Number of Visits | Frequency |\n\n\n| Speech Therapy |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Procedure Code | Code Description | Start Date | End Date | Number of Visits | Frequency |\n\n\n| Feeding Therapy |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Procedure Code | Code Description | Start Date | End Date | Number of Visits | Frequency |\n\n\n| Pulmonary Rehabilitation |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Procedure Code | Code Description | Start Date | End Date | Number of Visits | Frequency |\n\n\n| Cardiac Rehabilitation |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Procedure Code | Code Description | Start Date | End Date | Number of Visits | Frequency |\n\n\n| Chiropractic Care |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Procedure Code | Code Description | Start Date | End Date | Number of Visits | Frequency |\n\n\n| Other |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Procedure Code | Code Description | Start Date | End Date | Number of Visits | Frequency |\n\n\n| Clinical Documentation |\n| --- |\n| Provide clinical documentation to support medical necessity for the request. Include initial evaluation, current plan of care, physician order, current prescription, and recent progress notes as applicable. |","cbCaiaSKJOx6NHWM","https://ap.wps.com/l/cbCaiaSKJOx6NHWM","pdf",57315,"English","# Member Information\n## Ordering Provider Information\n## Treating Provider Information\n## Outpatient Therapy Request\n### Physical Therapy\n### Occupational Therapy\n### Speech Therapy\n### Feeding Therapy\n### Pulmonary Rehabilitation\n### Cardiac Rehabilitation\n### Chiropractic Care\n### Other\n# Clinical Documentation","[{\"question\":\"What information must be completed on the outpatient therapy prior authorization request form?\",\"answer\":\"The form requires member details (name, ID, date of birth), diagnosis and ICD-10 code, ordering provider information, treating provider information, and the outpatient therapy request including new or ongoing status and procedure code data with dates, number of visits, and frequency.\"},{\"question\":\"Where should the completed form be sent and how is authorization determined?\",\"answer\":\"Fax the completed form with requested supporting documentation to Highmark Health Options at 1-855-451-6664. Authorization is based on medical necessity.\"},{\"question\":\"What happens if the submission is incomplete or illegible?\",\"answer\":\"Incomplete information or illegible forms will delay processing. Include clinical documentation such as initial evaluation, current plan of care, physician order, current prescription, and recent progress notes as applicable.\"}]","Outpatient Therapy Services Prior Authorization Request Form - Authorization Instructions | PDF",1789633222]