Wv Medicaid Prior Authorization Form (Home Health)
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2WV MEDICAID PRIOR AUTHORIZATION FORM
FAX 1-844-633-8430 HOME HEALTH
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 __________________________________________
List Other Retro Reason:
Procedure Type:
Home Health
Patient Status:
Initial
Established
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**
Type of Admission/Procedure:
Emergency/Medically Urgent
Non-Urgent
Place of Service:
Homeless Shelter
Home
Assisted Living
Group Home
If Member is under age 18, are they enrolled in the Children with Special Health Care Needs Program?
Yes
No
List ICD Diagnosis Code(s):
Primary ICD DX: ___________________________________________________________________________________________________________________________
Symptoms: _______________________________________________________________________________________________________________________________
Other DX:
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