OUTPATIENT MEDICAID
Prior Authorization Fax Form
Complete and Fax to:
1-866-796-0526
This is a standard authorization request that may take up to 7 calendar days to process. If this is an expedited request, please contact us at 1-866-796-0530.
If this is a Medicare request, please fax to 877-617-0394.
Request for additional units. Existing Authorization
Units
*
INDICATES REQUIRED FIELD
MEMBER INFORMATION
Date of Birth
*
(MMDDYYYY)
Member ID/Medicaid ID
*
Last Name, First
REQUESTING PROVIDER INFORMATION
Requesting NPI
*
Requesting TIN
*
Requesting Provider Contact Name
Requesting Provider Name
Phone
Fax
SERVICING PROVIDER / FACILITY INFORMATION
Same as Requesting Provider
Servicing NPI
*
Servicing TIN
*
Servicing Provider Contact Name
Servicing Provider/Facility Name
Phone Fax
AUTHORIZATION REQUEST
Primary Procedure Code
*
Additional Procedure Code Start Date OR Admission Date
*
Diagnosis Code
*
(CPT/HCPCS) (Modifier)
(CPT/HCPCS) (Modifier)
(MMDDYYYY)
(ICD-10)
Additional Procedure Code
Additional Procedure Code
End Date OR Discharge Date Total Units/Visits/Days
(CPT/HCPCS) (Modifier)
(CPT/HCPCS) (Modifier) (MMDDYYYY)
OUTPATIENT SERVICE TYPE
*
(Enter the Service type number in the boxes)
760 Air Ambulance
712 Cochlear Implants & Surgery
Dental Anesthesia
911 Office Visit
721 Other Site
DME (Orthotics and Prosthetics)
711 Rental
700 Purchase
299 Drug Testing
922 Experimental and Investigational Services
709 Genet
ic Testing
249 Home Health
600 Home Infusion
927 Hospice
640 Injectable drugs and drugs given in
providers office
140 Observation
790 Occupational Therapy
(non-office or facility)
171 Outpatient Surgery
Pain Management
429 Office Visit
170 Other Site
101 Physical Therapy
(non-office or facility)
914 Respiratory Therapy (non-office or facility)
275 Sleep Study in Home
701 Speech Therapy
(non-office or facility)
499 Transplants (evals and consults) Office Visit
109 Transplants
(evals and consults) Other Visit
620 Vaccines Adult Pneumonia
630 Vaccines Shingles
Please contact NIA for radiology services, HN1 for office
therapies for members up to the age of 21, and Cenpatico
for behavioral health and substance abuse services
and contact Logisticare to arrange non-emergency
ambulance transportation.
ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED.
COPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION.
Disclaimer: 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.
Confidentiality: 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 intended 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.
Rev. 8 25 2016
FL-PAF-0675
*0675*
