Wv Medicaid Prior Authorization Form (Speech)

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WV MEDICAID PRIOR AUTHORIZATION FORM
FAX 1.844-633-8431 SPEECH
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
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 Procedure:
Emergency/Medically Urgent
Non-Urgent PATIENT STATUS:
New
Established
List ICD Diagnosis Code(s):
Primary ICD DX: ___________________________________________________________________________________________________________________________
Symptoms: _______________________________________________________________________________________________________________________________
Other DX:
**I certify that this patient meets the program eligibility criteria and that this equipment is a part of the course of
treatment and is reasonable, medically necessary and is most cost effective and is not a convenience item for the
recipient, family, attending practitioner or supplier. To my knowledge, the above information is accurate.
YES
NO
Please attach Certificate of Medical Necessity or appropriate documentation including signatures.

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