[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283882-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283882-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","wv-medicaid-outpatient-surgery-prior-authorization-request-form","WV Medicaid Outpatient Surgery Prior Authorization Request Form","","WV Medicaid outpatient surgery prior authorization request form used to register and submit authorization details for outpatient surgical services. The form collects requesting and submitting organization information, provider enrollment identifiers, contact details, member demographics, procedure and admission type, authorization type, and any retrospective reasons. It also captures ICD diagnosis codes, relevant diagnostic studies, service start date, surgical provider CPT codes, facility place of service, and procedure descriptions, including breast bra sizing when applicable, plus orthopedic, observation, NSAID, and activity modification questions.",{"@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/wv-medicaid-outpatient-surgery-prior-authorization-request-form/283882/",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/wv-medicaid-outpatient-surgery-prior-authorization-request-form/283882.png","ImageObject",442,249,{"name":42,"@type":43},"Aran","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",12,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"How is the prior authorization request submitted for outpatient surgery?","Question",{"text":63,"@type":64},"Registration on C3 is required to submit prior authorization requests whether by fax or electronically. The form includes the WV Medicaid prior authorization submission details and the fax number.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What provider enrollment requirements are stated on the form?",{"text":68,"@type":64},"The Referring/Ordering Provider must be actively enrolled with WV Medicaid, and the Place of Service/Servicing Provider must also be actively enrolled with WV Medicaid.",{"name":70,"@type":61,"acceptedAnswer":71},"Which medical information must be provided to support the request?",{"text":72,"@type":64},"The request includes relevant ICD diagnosis codes, relevant diagnostic studies (lab/imaging/radiology), service start date, CPT codes for surgical providers, facility/place of service for surgery, and a description of the surgical procedure(s).","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},283882,1791313660,{"code":4,"msg":82,"data":83},"success",[84,89,93,98,103,108,112,117,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"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":26,"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":22},137455076865,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","WV MEDICAID PRIOR AUTHORIZATION FORM  \nToday’s Date   FAX 1-844-633-8427 OUTPATIENT SURGERY  \nREGISTRATION ON C3 IS REQUIRED TO SUBMIT PRIOR AUTHORIZATION REQUESTS WHETHER BY FAX OR ELECTRONICALLY.  \nDETERMINATIONS ARE AVAILABLE ON [HTTPS://PROVIDERPORTAL.KEPRO.COM](HTTPS://PROVIDERPORTAL.KEPRO.COM)  \nC3 Requesting/Submitting Organization ________________________________________________________ Please list exactly as registered on C3  \nAddress, City, State, Zip _______________________________________________________________________________________  \nC3 Requesting/Submitting Organization NPI ________________________________________________________ Please list exactly as registered on C3  \nPerson Submitting Request _____________________ Phone ____________________ Fax _____________________ Email_________________________  \nReferring/Ordering Provider ( Per policy the Referring/Ordering Provider must be actively enrolled with WV Medicaid)  \n\n| | Name\u003Cbr>Do not write “See Above” | |  | NPI Number |  | |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| \u003Cbr>Contact Information |  | | Phone |  | Fax: |  | |\n\nPlace of Service/Servicing Provider ( Per policy the Place of Service/Servicing Provider must be actively enrolled with WV Medicaid)  \n\n| | Name\u003Cbr>Do not write “See Above” | | NPI Number | |\n| --- | --- | --- | --- | --- |\n| \u003Cbr>Address,\u003Cbr>City, State, Zip |  | | |  |\n\nMember Medicaid Number   DOB   \nMember First Name   Last Name    \nMember Address, City, State, ZIP    \nProcedure Type: OP SURGERY Type of Admission/Procedure: Emergency/Medically Urgent Non-Urgent  \nAuthorization Type: Prior Authorization  \nRetrospective Request, if applicable list the appropriate reason:  \nDenied by Member’s Primary Payer Retrospective Medicaid Eligibility  \nList Other Retro Reason:  \nFor Members under age 21, is this request an EPSDT referral? Yes NO ** If yes, please submit the most current EPSDT form on file**  \nPlace of Service:  \nOffice Urgent Care Facility Inpatient Hospital OP Hospital Ambulatory Surgical Center Birthing Center Military Treatment Facility  \nLIST ALL RELEVANT ICD DIAGNOSIS CODE(S):  \nPrimary DX:   Symptoms:    \nOther DX:  \nRELEVANT DIAGNOSTIC (LAB.IMAGING.RADIOLOGY) STUDIES PERFORMED  \nIf you have relevant diagnostics that you would like to include please indicate such on this form or include as an attachment with the submission:  \nSERVICE START DATE:    \n**Please request the Primary service code for both the Referring/Rendering Provider and the Servicing Provider/Location/Facility**  \n1. SURGICAL PROVIDER (PHYSICIAN) CPT CODE: Primary: Secondary:   \nLIST FACILITY/PLACE OF SERVICE FOR SURGERY:    \n2. SURGICAL PROVIDER (PHYSICIAN) CPT CODE: Primary: Secondary:   \nLIST FACILITY/PLACE OF SERVICE FOR SURGERY:    \n3. SURGICAL PROVIDER (PHYSICIAN) CPT CODE: Primary: Secondary:   \nLIST FACILITY/PLACE OF SERVICE FOR SURGERY:    \nDESCRIBE SURGICAL PROCEDURE(S) LISTED ABOVE:  \nIF SURGICAL PROCEDURE IS BREAST-RELATED PLEASE INDICATE BRA SIZE (PRE-SURGERY)   \nDoes this admission follow observation? Yes No Date Placed in Observation:    \nIf Yes, describe the progression of symptoms/illness plus treatment administered during observation:  \nIs this an Orthopedic Procedure? Yes No If Yes, please provide description:  \nHave NSAIDS been tried? Yes No If yes, please mark duration0-3 months 3-6 months 6-9 months  12+ months 9-12 months If yes list outcome, if no list why:  \nHas activity modification been tried? Yes No If yes, please mark duration 0-3 months 3-6 months 6-9 months  12+ months 9-12 months If yes list outcome including duration, if no list why:  \nPlease provide description of known Medical History and relation to request :  \nIs the member currently taking medication? Yes No  \nIf yes, please attach a MAR showing name, strength, route, prescribed date, quantity and frequency","cbCaisCLlPRiLsvX","https://ap.wps.com/l/cbCaisCLlPRiLsvX","pdf",44135,"English","# Provider and Request Information\n## Member and Authorization Details\n## Diagnosis, Diagnostics, and Procedure Codes\n## Clinical Questions and Supporting Documents","[{\"question\":\"How is the prior authorization request submitted for outpatient surgery?\",\"answer\":\"Registration on C3 is required to submit prior authorization requests whether by fax or electronically. The form includes the WV Medicaid prior authorization submission details and the fax number.\"},{\"question\":\"What provider enrollment requirements are stated on the form?\",\"answer\":\"The Referring/Ordering Provider must be actively enrolled with WV Medicaid, and the Place of Service/Servicing Provider must also be actively enrolled with WV Medicaid.\"},{\"question\":\"Which medical information must be provided to support the request?\",\"answer\":\"The request includes relevant ICD diagnosis codes, relevant diagnostic studies (lab/imaging/radiology), service start date, CPT codes for surgical providers, facility/place of service for surgery, and a description of the surgical procedure(s).\"}]","WV Medicaid Outpatient Surgery Prior Authorization Request Form | PDF",1789621359]