Wv Medicaid Prior Authorization Form (Vision)
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1WV MEDICAID PRIOR AUTHORIZATION FORM
FAX 1.844-633-8431 VISION
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 __________________________________________
Member Address, City, State, ZIP
_______________________________________________________________________________________________
List Other Retro Reason:
Authorization Type:
Prior Authorization
Place of Service: OFFICE
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**
Date of Last Vision Exam: ___________________
Type of Admission/Procedure:
Emergency/Medically Urgent
Non-Urgent
List ALL Relevant ICD Diagnosis Code(s):
Primary DX:
________________________________ Symptoms: ______________________________________________________________
92019
EYE EXAM & TREATMENT
POS: 11 OFFICE # of Units: 1 Start Date:______/_____/_____
92326
REPLACEMENT OF CONTACTS LENS
POS: 11 OFFICE # of Units: 1 Start Date:______/_____/_____
92065
ORTHOPTIC/PLEOPTIC TRAINING
POS: 11 OFFICE # of Units: 1 Start Date:______/_____/_____
IF THIS IS A REPAIR OR REPLACEMENT REQUEST PLEASE ANSWER THE FOLLOWING QUESTION:
HAS VISUAL APPLIANCE BEEN REPAIRED OR REPLACED WITHIN THE PAST YEAR?
Yes
NO
•
IF YES, PLEASE INDICATE HOW MANY TIMES VISUAL APPLIANCES HAVE BEEN REPAIRED OR REPLACED.
•
PLEASE INDICATE NUMBER OF TIMES: ___________________
ADDITIONAL ANNOTATIONS:
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