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Requires today’s date and provider/organization registration details, including submitting and referring provider enrollment information. Collects member demographics, procedure and authorization type, retrospective reasons when applicable, admission and place of service. Includes ICD diagnosis codes, requested CPT codes with units and start dates, attachment confirmation for physician orders, request period and visit frequency, treatment rationale, goals, and documentation checklist for submission.",{"@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/wv-medicaid-prior-authorization-form-for-ptot-paper/283884/",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/wv-medicaid-prior-authorization-form-for-ptot-paper/283884.png","ImageObject",442,249,{"name":88,"@type":89},"Ben Jamin","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":30},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"How can prior authorization requests be submitted for WV Medicaid PT/OT?","Question",{"text":108,"@type":109},"Requests must be submitted through ATREZZO registration, either by fax or electronically. Determinations are available on the KEPRO portal.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What provider enrollment requirement applies to the referring/ordering provider?",{"text":113,"@type":109},"Per policy, the referring/ordering provider must be actively enrolled with WV Medicaid.",{"name":115,"@type":106,"acceptedAnswer":116},"What information is required for requested services and coding?",{"text":117,"@type":109},"The form collects CPT requested with number of units and start dates, plus all relevant ICD diagnosis codes. It also asks whether physician orders for each code are attached and requires reasons if not attached.","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},283884,1789964164,{"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":30,"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},2336478466772,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","WV MEDICAID PRIOR AUTHORIZATION FORM  \nToday’s Date   FAX 1-844-633-8431 PT/OT  \nREGISTRATION ON ATTREZO IS REQUIRED TO SUBMIT PRIOR AUTHORIZATION REQUESTS WHETHER BY FAX OR ELECTRONICALLY.  \nDETERMINATIONS ARE AVAILABLE ON [https://portal.kepro.com/](https://portal.kepro.com/)  \nATTREZO Requesting/Submitting Organization   Please list exactly as registered on ATREZZO  \nAddress, City, State, Zip   ATTREZO Requesting/Submitting Organization NPI   Please list exactly as registered on ATTREZO Person 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| | 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| | Address,\u003Cbr>City, State, Zip | |  |\n\nMember Medicaid Number   DOB   \nMember First Name   Last Name    \nMember Address, City, State, ZIP    \nProcedure Type:  PT OT Request Type:  Initial  Established  \nAuthorization Type: Prior Authorization  \nRetrospective Request, if applicable list the appropriate reason:  \nDenied by Member’s Primary Payer Retrospective Medicaid Eligibility  \nFor Members under age 21, is this request an EPSDT referral? Yes NO **If yes, please submit the most current EPSDT form on file** Type of Admission: Emergency/Medically Urgent Non-Urgent Place of Service:  Office OP Hospital  \nList Other Retro Reason:  \nList ALL Relevant ICD Diagnosis Code(s):  \nPrimary DX:   Symptoms:    \nOther DX:  \nCPT Requested:  \\# OF UNITS  Start Date:  CPT Requested:  \\# OF UNITS  Start Date:   \nCPT Requested:  \\# OF UNITS  Start Date:   \nAre the physician orders for each code attached?  Yes   No If No, please list why:  \nPERIOD OF REQUEST:  30 days  60 days  90 days FREQUENCY OF VISITS: Biweekly Monthly Weekly  \nDECLINING FREQUENCY EXPLANATION:   SUBJECTIVE COMPLAINTS:   PROGNOSIS:    \nOBJECTIVE FINDINGS:  \n_________________________________________________________________________________  \nEXTENUATING CIRCUMSTANCES:   HISTORY OF INJURY AND/OR SURGICAL PROCEDURE FOR CURRENT DIAGNOSIS:    \n\n| SHORT TERM GOALS + EXPECTED DATE MET   |\n| --- |\n| LONG TERM GOALS + EXPECTED DATE MET  |\n\nHAVE NSAIDS BEEN USED? Yes NO If yes, duration: 0-3 months 3-6 months 6-9 months 9-12 months +12 months If yes list outcome:   If no list why:   HAS ACTIVITY MODIFICATION BEEN TRIED? Yes NO If Yes, Length:  1-6 Weeks  7-12 Weeks  More than 12 Weeks If yes list outcome:   If no list why:    \nADDITIONAL TREATMENT PLAN INFORMATION:  \n• Chiropractic Services Utilized Yes NO  \n• Chiropractic Services Ongoing Yes NO  \n• Home Exercise Program Prescribed Yes NO  \n• Home Exercise Program Frequency Daily Every Other Day 3 Times per week or less Other:   \n• Home Exercise Program Duration  1-6 Weeks  7-12 Weeks  More than 12 Weeks  \n• Home Exercise Program Outcomes:   \nPLEASE INCLUDE THE FOLLOWING INFORMATION WITH SUBMISSION:  \n• Signed & Dated Physicians Order for Each Requested Service  \n• Relevant Diagnostic Studies & Medication List  \n• Progress/Treatment Notes  \nNOTES:","cbCaiiOH68bkusEk","https://ap.wps.com/l/cbCaiiOH68bkusEk","pdf",149135,"English","# Provider and Organization Details\n## Registration, Submitting, Referring/Ordering, and Place of Service\n# Member and Request Information\n## Member demographics and procedure/authorization type\n# Clinical and Coding Requirements\n## ICD diagnosis codes, requested CPT, units, start dates, attachments\n# Request Parameters and Treatment Plan\n## Period of request, frequency, goals, and outcome-related sections\n# Submission Checklist\n## Required documents and notes","[{\"question\":\"How can prior authorization requests be submitted for WV Medicaid PT/OT?\",\"answer\":\"Requests must be submitted through ATREZZO registration, either by fax or electronically. Determinations are available on the KEPRO portal.\"},{\"question\":\"What provider enrollment requirement applies to the referring/ordering provider?\",\"answer\":\"Per policy, the referring/ordering provider must be actively enrolled with WV Medicaid.\"},{\"question\":\"What information is required for requested services and coding?\",\"answer\":\"The form collects CPT requested with number of units and start dates, plus all relevant ICD diagnosis codes. It also asks whether physician orders for each code are attached and requires reasons if not attached.\"}]","WV Medicaid Prior Authorization Form for PT/OT - Paper | PDF",1789621364]