INPATIENT 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.
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INDICATES REQUIRED FIELD
MEMBER INFORMATION
Date of Birth
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Member ID/Medicaid ID
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Last Name, First
*0676*
(ICD-10)
(MMDDYYYY)
REQUESTING PROVIDER INFORMATION
Requesting NPI
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Requesting TIN
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Requesting Provider Contact Name
Requesting Provider Name
Phone Fax
SERVICING PROVIDER / FACILITY INFORMATION
Same as Requesting Provider
Servicing NPI
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Servicing TIN
Servicing Provider Contact Name
Servicing Provider/Facility Name
Phone
Fax
(MMDDYYYY)
AUTHORIZATION REQUEST
ICD-10
Primary Procedure Code
Start Date OR Admission Date
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Diagnosis Code
*
(MMDDYYYY)
Additional Procedure Code
(CPT/HCPCS) (Modifier)
(CPT/HCPCS) (Modifier)
Discharge Date (if applicable) otherwise
Length of Stay will be based on Medical Necessity
INPATIENT SERVICE TYPE
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(Enter the Service type number in the boxes)
Delivery
779 C-Section
720 Vaginal Delivery
Inpatient Rehab
479 Inpatient Hospital
220 Comprehensive Inpatient
Rehab Facility
970 Medical
904 Nursing Facility (Residential/ Custodial Care)
402 Skilled Nursing Facility
414 Premature/False Labor
492 Sub-Acute
411 Surgical
Transplant
209 Surgery
419 Work-up
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. 10 27 2015
FL-PAF-0676
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