[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-283851-105":53,"doc-detail-283851-en":127},{"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":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","plan-mmp-outpatient-authorization-form-incontinence-supplies","PLAN (MMP) OUTPATIENT AUTHORIZATION FORM - Incontinence Supplies","","This outpatient authorization form supports requests for additional incontinence supply units under Superior HealthPlan STAR+PLUS Medicare-Medicaid (Plan MMP). It collects member demographics, requesting and servicing provider/facility identifiers, authorization request dates, diagnosis (ICD-10), procedure codes (CPT/HCPCS) with modifiers, and the total units/visits/days. The form specifies standard and expedited decision timelines and requires expedited requests to be signed by the requesting physician, with required supporting clinical documentation for timely determination. It also states that authorization does not guarantee payment and must meet eligibility and medical necessity requirements.",{"@graph":63,"@context":119},[64,80,102],{"@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/plan-mmp-outpatient-authorization-form-incontinence-supplies/283851/",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/plan-mmp-outpatient-authorization-form-incontinence-supplies/283851.png","ImageObject",442,249,{"name":88,"@type":89},"Sarah ","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-30","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",13,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information is required to submit an outpatient authorization request?","Question",{"text":109,"@type":110},"The form requires member details, requesting and servicing provider identifiers, authorization request dates, diagnosis code (ICD-10), procedure codes (CPT/HCPCS) with modifiers, and total units/visits/days, along with the outpatient service type selection. All required fields must be completed or the form will be rejected.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What are the decision timelines for standard vs. expedited authorization requests?",{"text":114,"@type":110},"Standard authorization decisions are made no later than 3 business days after receipt. Expedited decisions are made no later than 1 business day after receipt, and expedited requests must be signed by the requesting physician.",{"name":116,"@type":107,"acceptedAnswer":117},"Does approval of authorization guarantee payment?",{"text":118,"@type":110},"No. Authorization is not a guarantee of payment. The member must be eligible at the time services are rendered, and services must be covered, medically necessary, and subject to prior authorization per plan policy.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},283851,1791354528,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},962085320529,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Complete and Fax to:  \nSUPERIOR HEALTHPLAN STAR+PLUS MEDICARE-MEDICAID 1-877-808-9368  \nPLAN (MMP) OUTPATIENT AUTHORIZATION FORM Incontinence Supplies Fax:  \n1-800-690-7030  \nRequest for additional units. Existing Authorization  Units  STANDARD: Standard authorization decisions will be made no later than 3 business days after receipt of the request for service.  \n EXPEDITED: Expedited service authorizations decisions will be made no later than one business day after the receipt of the request for service.  \nEXPEDITED REQUESTS MUST BE SIGNED BY THE REQUESTING PHYSICIAN.  \nX  \n* INDICATES REQUIRED FIELD ~~ ~~  \nMEMBER INFORMATION  \nMember ID*  \nLast Name, First  \nDate of Birth*  \n(MMDDYYYY)  \nREQUESTING PROVIDER INFORMATION  \n*0907*  \nRequesting NPI* Requesting TIN* Requesting Provider Contact Name  \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  \nAs of 10/01/2015, only ICD-10 codes are accepted.  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nStart Date OR Admission Date*  \n(MMDDYYYY)  \nEnd Date OR Discharge Date  \n(MMDDYYYY)  \nDiagnosis Code*  \n(ICD-10)  \nTotal Units/Visits/Days  \n| OUTPATIENT SERVICE TYPE* (Enter the Service type number in the boxes)  |  |  |  |\n| --- | --- | --- | --- |\n| 422\u003Cbr>401\u003Cbr>417\u003Cbr>120\u003Cbr>299\u003Cbr>709\u003Cbr>249\u003Cbr>729\u003Cbr>410 | Biopharmacy\u003Cbr>Cardiac Pulmonary Rehab\u003Cbr>DME (Orthotics and Prosthetics)\u003Cbr>Rental\u003Cbr>Purchase\u003Cbr>Drug Testing\u003Cbr>Genetic Testing\u003Cbr>Home Health Neuropsych Testing Observation (only > 48 hrs)\u003Cbr>$\u003Cbr>(Purchase Price) | 794 Outpatient Services\u003Cbr>171 Outpatient Surgery\u003Cbr>997 Office Visit/Consult (non par only)\u003Cbr>202 Pain Management\u003Cbr>420 Pulmonary Rehab\u003Cbr>201 Sleep Study\u003Cbr>Therapy\u003Cbr>790 Occupational\u003Cbr>101 Physical\u003Cbr>701 Speech | 650 Radiation Therapy\u003Cbr>617 Non-Emergent Medical\u003Cbr>Transportation-Ambulance Only\u003Cbr>290 Hyperbaric Oxygen Therapy\u003Cbr>Outpatient Services Example:\u003Cbr>-Skin Debridement/Wound Care\u003Cbr>Home Health Examples:\u003Cbr>-Skilled Nursing Visits\u003Cbr>-Home Health Aid |\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 Rev. 03 14 2016  \nintended 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. TX-PAF-0907  \nSHP_ 2015289C","cbCaifUdB62uNsmh","https://ap.wps.com/l/cbCaifUdB62uNsmh","pdf",751417,"English","# Member information\n# Requesting provider information\n# Servicing provider/facility information\n# Authorization request\n## Outpatient service type\n## Home health and outpatient examples","[{\"question\":\"What information is required to submit an outpatient authorization request?\",\"answer\":\"The form requires member details, requesting and servicing provider identifiers, authorization request dates, diagnosis code (ICD-10), procedure codes (CPT/HCPCS) with modifiers, and total units/visits/days, along with the outpatient service type selection. All required fields must be completed or the form will be rejected.\"},{\"question\":\"What are the decision timelines for standard vs. expedited authorization requests?\",\"answer\":\"Standard authorization decisions are made no later than 3 business days after receipt. Expedited decisions are made no later than 1 business day after receipt, and expedited requests must be signed by the requesting physician.\"},{\"question\":\"Does approval of authorization guarantee payment?\",\"answer\":\"No. Authorization is not a guarantee of payment. The member must be eligible at the time services are rendered, and services must be covered, medically necessary, and subject to prior authorization per plan policy.\"}]","PLAN (MMP) OUTPATIENT AUTHORIZATION FORM - Incontinence Supplies | PDF",1789620896]