Wv Medicaid Prior Authorization Form (Inpatient)
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2WV MEDICAID PRIOR AUTHORIZATION FORM
FAX 1.844-633-8426 INPATIENT
Today’s Date ___________________
REGISTRATION ON C3 IS REQUIRED TO SUBMIT PRIOR AUTHORIZATION REQUESTS WHETHER BY FAX OR ELECTRONICALLY.
DETERMINATIONS ARE AVAILABLE ON
C3 Requesting/Submitting Organization
________________________________________________________ Please list exactly as registered on C3
Address, City, State, Zip
_______________________________________________________________________________________
C3 Requesting/Submitting Organization NPI
________________________________________________ Please list exactly as registered on C3
Person Submitting Request _____________________ Phone ____________________ Fax _____________________ Email_________________________
Referring/Ordering Provider
(
Per policy the Referring/Ordering Provider must be actively enrolled with WV Medicaid)
Name
NPI Number
Do not write “See Above”
Contact Information
Phone
Fax:
Place of Service/Servicing Provider
(
Per policy the Place of Service/Servicing Provider must be actively enrolled with WV Medicaid)
Name
NPI Number
Do not write “See Above”
Address,
City, State, Zip
Member Medicaid Number ________________________________________________ DOB_______________________
Member First Name
______________________________________________
Last Name __________________________________________
1
Procedure Type:
Elective
General/Acute
Organ Transplant
Place of Service: INPATIENT HOSPITAL WV001
List Other Retro Reason:
ADMISSION DATE:
DISCHARGE DATE:
Authorization Type:
Prior Authorization
Retrospective Request, if applicable list the appropriate reason:
Denied by Member’s Primary Payer
Retrospective Medicaid Eligibility
For Members under age 21, is this request an EPSDT referral?
Yes
NO **If yes, please submit the most current EPSDT form on file**
***The WV Bureau for Medical Services defines MEDICALLY URGENT as follows: A delay in services could seriously jeopardize 1. the life or health of
the consumer; 2. the ability of the consumer to regain function; 3. in the opinion of a physician with knowledge of the consumer's condition, would
subject the consumer to severe pain that cannot be adequately managed without care or treatment that is the subject of the case.***
Type of Admission
Direct
Direct/Medically Urgent
Elective
Elective/Medically Urgent
Emergency
Non-Elective
Non-Elective/Medically Urgent
Transplant
Transplant/Medically Urgent
Emergency/Medically Urgent
Type of Unit
Coronary Care Unit
Medical/Surgical
Critical Care Unit
Neonatal Intensive Care Unit (NICU)
Intensive Care Unit (ICU)
Special Care Nursery
Intermediate Care
Telemetry
Other: _____________________________
Does this admission follow observation?
Yes
No
If yes, Date of Observation
______________________________
If Yes, describe the progression of symptoms/illness plus treatment administered during observation:
List ICD Diagnosis Code(s):
Primary ICD DX: ______________________________________________________________________________________________________________
Symptoms: __________________________________________________________________________________________________________________
Other DX:
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