[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283808-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283808-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","prior-authorization-request-form-complete-utilization-management-details","Prior Authorization Request Form - Complete Utilization Management Details","","Prior Authorization Request Form for submitting medical requests for review by utilization management. It collects request metadata such as date, type of request (urgent, standard, retrospective), treatment setting, and request categories including extension, initial, cancel, and changes. The form gathers member demographics, provider and facility identifiers, referring physician information, diagnosis codes, and procedure details with units and date ranges. It also sets submission requirements for clinical information and CPT/ICD-10 codes and clarifies urgent-condition definitions and 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/prior-authorization-request-form-complete-utilization-management-details/283808/",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/prior-authorization-request-form-complete-utilization-management-details/283808.png","ImageObject",442,249,{"name":42,"@type":43},"Liam","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-23","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",14,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information is required for a prior authorization request to be processed?","Question",{"text":63,"@type":64},"All fields must be completed, including clinical information and the required CPT and ICD-10 codes.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What types of request can be selected on the form?",{"text":68,"@type":64},"The form supports selecting request type options such as extension, initial, cancel, and changes, along with additional clinical categories like discharge planning and transplant-related options.",{"name":70,"@type":61,"acceptedAnswer":71},"Does authorization guarantee payment?",{"text":72,"@type":64},"No. Authorization is not a guarantee of payment; payment depends on benefit coverage rules, member eligibility, and contract limitations at the time of service.","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},283808,1790290372,{"code":4,"msg":82,"data":83},"success",[84,89,94,98,103,108,112,117,122],{"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":55,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},"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":33,"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":26},8796095461564,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Prior Authorization Request Form  \nPlease type this document to ensure accuracy and to expedite processing. All fields must be completed for the request to be processed.  \nPlease make a selection where applicable throughout the document.  \n\n| DATE |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| TYPE OF REQUEST |  |   URGENT STANDARD RETROSPECTIVE\u003Cbr>____ ____ |  |  |  |\n| TREATMENT SETTING |  |  |   INPATIENT OUTPATIENT\u003Cbr>____ |  |  |\n| REQUEST TYPE |   EXTENSION   INITIAL   CANCEL   CHANGES DOS/SETTING |  |  |  |  |\n|   ADDITIONAL CLINICAL   DISCHARGE PLANNING |  |  |  |  |  |\n|   TRANSPLANT EVALUATION NOTIFICATION (IN-NETWORK PROVIDERS ONLY) |  |  |  |  |  |\n|   TRANSPLANT LISTING (IN OR OUT OF NETWORK) |  |  |  |  |  |\n| OTHER\u003Cbr>____ |  |  |  |  |  |\n| PREVIOUS AUTHORIZATION NUMBER |  |  |  |  |  |\n| CONTACT NAME |  |  |  |  |  |\n| CONTACT PHONE |  |  |  |  | CONTACT FAX |\n\nMEMBER INFORMATION  \n\n| LAST NAME |  |  |  |\n| --- | --- | --- | --- |\n| FIRST NAME |  |  |  |\n| MEMBER ID |  |  |  |\n| MEMBER PHONE NUMBER |  | DATE OF BIRTH |  |\n| MEMBER STREET ADDRESS |  |  |  |\n| CITY | STATE |  | ZIP |\n\nMCO-OH_266330100 Page 1 of 4  \nPROVIDER INFORMATION  \n\n| PROVIDER NAME |  |  |  |\n| --- | --- | --- | --- |\n| PROVIDER TIN | PROVIDER NPI |  |  |\n| PROVIDER PHONE NUMBER | PROVIDER FAX NUMBER |  |  |\n| PROVIDER STREET ADDRESS |  |  |  |\n| CITY |  | STATE | ZIP |\n| PROVIDER STATUS   PAR   NON PAR IN CREDENTIALING\u003Cbr>____ |  |  |  |\n| FACILITY NAME |  |  |  |\n| FACILITY TIN | FACILITY NPI |  |  |\n| FACILITY PHONE NUMBER | FACILITY FAX NUMBER |  |  |\n| FACILITY STREET ADDRESS |  |  |  |\n| CITY |  | STATE | ZIP |\n| PROVIDER STATUS   PAR   NON PAR IN CREDENTIALING\u003Cbr>____ |  |  |  |\n\n\n| REFERRING PHYSICIAN NAME (IF DIFFERENT FROM ABOVE) |  |  |\n| --- | --- | --- |\n| REFERRING PHYSICIAN TIN |  |  |\n| REFERRING PHYSICIAN NPI |  |  |\n| REFERRING PHYSICIAN PHONE NUMBER |  |  |\n| REFERRING PHYSICIAN FAX NUMBER |  |  |\n| REFERRING PHYSICIAN STREET ADDRESS |  |  |\n| CITY | STATE | ZIP |\n| PROVIDER STATUS   PAR   NON PAR IN CREDENTIALING\u003Cbr>____ |  |  |\n\nMCO-OH_266330100 Page 2 of 4  \n\n| MEDICAL SECTION |  |  |\n| --- | --- | --- |\n|  |  |  |\n| DIAGNOSIS CODE |  |  |\n|  |  |  |\n\n\n| PROCEDURE CODE | START\u003Cbr>DATE | END\u003Cbr>DATE | NUMBER OF\u003Cbr>UNITS | CODE DESCRIPTION |\n| --- | --- | --- | --- | --- |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n\nMCO-OH_266330100 Page 3 of 4  \n\n| MEDICAL SECTION |\n| --- |\n|  |\n| NOTES |\n\nPLEASE FAX TO 1-888-989-0019  \nUTILIZATION MANAGEMENT DEPARTMENT PHONE: 1-888-312-5713 OPTION 1 OPTION 4  \nTRANSPLANT UNIT FAX NUMBER: 1-844-796-1177  \nTRANSPLANT UNIT DIRECT TOLL-FREE NUMBER: 1-833-983-7229  \nPROVIDERS ARE RESPONSIBLE FOR OBTAINING PRIOR AUTHORIZATION FOR SERVICES PRIOR TO SCHEDULING. PLEASE SUBMIT CLINICAL INFORMATION, AS NEEDED, TO SUPPORT MEDICAL NECESSITY OF THE REQUEST. REQUESTS WILL NOT BE PROCESSED IF MISSING CLINICAL INFORMATION OR CPT AND ICD-10 CODES. AS A REMINDER, AUTHORIZATION IS NOT A GUARANTEE OF PAYMENT; PAYMENT IS SUBJECT TO BENEFIT COVERAGE RULES, INCLUDING MEMBER ELIGIBILITY AND ANY CONTRACTUAL LIMITATIONS IN EFFECT AT THE TIME OF SERVICE.  \nURGENT MEDICAL CONDITION: ANY ILLNESS, INJURY, OR SEVERE CONDITION WHICH, UNDER REASONABLE STANDARDS OF MEDICAL PRACTICE, WOULD BE DIAGNOSED AND TREATED WITHIN A 24-HOUR PERIOD AND, IF LEFT UNTREATED, COULD RAPIDLY BECOME A CRISIS OR EMERGENCY MEDICAL CONDITION. THE TERM ALSO INCLUDES SITUATIONS WHERE A PERSON’S DISCHARGE FROM A HOSPITAL WILL BE DELAYED UNTIL SERVICES ARE APPROVED OR A PERSON’S ABILITY TO AVOID HOSPITALIZATION DEPENDS UPON PROMPT APPROVAL OF SERVICES.  \nMCO-OH_266330100 Page 4 of 4","cbCaifqyJFm2D0Jr","https://ap.wps.com/l/cbCaifqyJFm2D0Jr","pdf",179760,"English","# Prior Authorization Request Details\n## Request Options\n## Member Information\n## Provider and Facility Information\n## Referring Physician Information\n## Medical Section\n## Submission Instructions","[{\"question\":\"What information is required for a prior authorization request to be processed?\",\"answer\":\"All fields must be completed, including clinical information and the required CPT and ICD-10 codes.\"},{\"question\":\"What types of request can be selected on the form?\",\"answer\":\"The form supports selecting request type options such as extension, initial, cancel, and changes, along with additional clinical categories like discharge planning and transplant-related options.\"},{\"question\":\"Does authorization guarantee payment?\",\"answer\":\"No. Authorization is not a guarantee of payment; payment depends on benefit coverage rules, member eligibility, and contract limitations at the time of service.\"}]","Prior Authorization Request Form - Complete Utilization Management Details | PDF",1789620095]