[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-286837-105":53,"doc-detail-286837-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","priority-health-medicare-part-d-prior-authorization-form","Priority Health - Medicare Part D Prior Authorization Form","","This document is a formal Medical Prior Authorization Fax Form provided by Priority Health for healthcare providers. It is designed to facilitate the request process for medical services, including elective procedures, outpatient, and inpatient admissions. The form requires comprehensive patient information, diagnosis codes, procedure details, and provider contact information to ensure accurate processing. Additionally, it contains mandatory instructions regarding Medicaid program compliance, specifically the requirement for providers to enroll in the CHAMPS system to receive reimbursement for services rendered to Medicaid beneficiaries. The document serves as an essential administrative tool for coordinating pre-service determinations and streamlining the prior authorization workflow within the Priority Health network.",{"@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/priority-health-medicare-part-d-prior-authorization-form/286837/",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/priority-health-medicare-part-d-prior-authorization-form/286837.png","ImageObject",442,249,{"name":88,"@type":89},"Adam","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-20","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":73},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required to process a prior authorization request?","Question",{"text":108,"@type":109},"The request must include complete patient details, diagnosis and procedure codes, specific treatment or testing information, and all relevant supporting clinical documentation.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How do providers receive reimbursement for services provided to Medicaid beneficiaries?",{"text":113,"@type":109},"Providers must enroll in the Community Health Automated Medicaid Processing System (CHAMPS) to be eligible for reimbursement from any Medicaid program.",{"name":115,"@type":106,"acceptedAnswer":116},"Where should the completed prior authorization form be sent?",{"text":117,"@type":109},"The form should be faxed to the number provided at the top of the document: 888 647-6152.","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},286837,1789631605,{"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":9,"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":125,"read_time":4},1374404737137,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Medical Prior Authorization Fax Form To: 888 647-6152  \nForm  \nPrior to completion, please review the list of specialty prior authorization forms available on our website.  \nDate:    *Provider Pre-service Organization Determination  \n*Check only if requesting a pre-service determination for a Part C Medicare Advantage beneficiary  \n**See important message below if requesting services for a Medicaid Plan member Member:  \nLast name:   First name:   Priority Health ID \\#:   Date of birth:   \nReason for Referral:  \n Non-participating Priority Health Provider  Outpatient Transplant Related  \n Elective Procedure  Inpatient  \nDiagnosis:   Diagnosis code(s):   Treatment/testing:   Procedure code(s):   Date of visit/procedure:   Number of visits:    \nRequested By:  \nProvider name:   Phone:  Fax:  Provider tax ID (required):   Specialty:  Address:   Contact name:    \nDirected To:  \nProvider name:   Facility:  Provider tax ID (required):   Facility tax ID (required):  Address:   Address:   \nProvider phone:   Fax:   Facility phone:   Fax:   Contact name:   Contact name:    \nFor Inpatient Admissions:  \nDate of admission:   UR phone:  UR fax:  Form completed by:   Phone:   \nAdditional Information (i.e. what participating provider(s) has the member already seen if Out of Network request?):  \nTo facilitate prompt and accurate processing, the information above must be complete and all supporting clinical documentation related to this request MUST be submitted with this form.  \n**In order to receive payment from any Medicaid program, new federal regulation requires that those providing services to a Medicaid beneficiary must enroll in CHAMPS (Community Health Automated Medicaid  Processing System) to receive reimbursement. For more information, go to: [https://milogintp.michigan.gov](https://milogintp.michigan.gov)[ ](https://milogintp.michigan.gov)Contact the Medicaid Provider Helpline 1-800-292-2550  08/2020   \nPrint","cbCaidnu5eHynuRp","https://ap.wps.com/l/cbCaidnu5eHynuRp","pdf",470810,"English","# Member Information\n# Referral Details\n## Diagnosis and Treatment Information\n# Provider and Facility Identification\n## Requesting Provider\n## Directed Provider and Facility\n# Inpatient Admissions Data\n# Additional Clinical Information\n# Medicaid Enrollment Compliance","[{\"question\":\"What information is required to process a prior authorization request?\",\"answer\":\"The request must include complete patient details, diagnosis and procedure codes, specific treatment or testing information, and all relevant supporting clinical documentation.\"},{\"question\":\"How do providers receive reimbursement for services provided to Medicaid beneficiaries?\",\"answer\":\"Providers must enroll in the Community Health Automated Medicaid Processing System (CHAMPS) to be eligible for reimbursement from any Medicaid program.\"},{\"question\":\"Where should the completed prior authorization form be sent?\",\"answer\":\"The form should be faxed to the number provided at the top of the document: 888 647-6152.\"}]","Priority Health - Medicare Part D Prior Authorization Form | PDF"]