Wv Medicaid Prior Authorization Form (Speech) Page 2
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2Service Code:
Service Code:
Service Code:
Place of Service:
Place of Service:
Place of Service:
Office
Office
Office
Home
Home
Home
Public Health Clinic
Public Health Clinic
Public Health Clinic
Rural Health Clinic
Rural Health Clinic
Rural Health Clinic
Units:
Units:
Units:
Period of Request:
Period of Request:
Period of Request:
30 Days
60 Days
90 Days
30 Days
60 Days
90 Days
30 Days
60 Days
90 Days
Frequency:
Frequency:
Frequency:
Weekly
Biweekly
Monthly
Weekly
Biweekly
Monthly
Weekly
Biweekly
Monthly
Duration of Individual Therapy Services:
Duration of Individual Therapy Services:
Duration of Individual Therapy Services:
1 hour
15 Minutes
1 hour
15 Minutes
1 hour
15 Minutes
30 Minutes
Event
30 Minutes
Event
30 Minutes
Event
Declining Frequency Explanation:
__________________________________________________________________________________________________
REQUIRED WITH EACH SPEECH REQUEST
ATTACHED?
Certificate of Medical Necessity
Date of CMN
_______________
Yes
No
N/A
Signed Physician’s Order(s)
Date of Order _______________
Yes
No
Most Recent Progress Notes
Date of Notes _______________
Yes
No
Waiver Letter for School-Aged Children
Date of Letter _______________
Yes
No
N/A
Treatment Care Plan
Date of TCP
_______________
Yes
No
Members <21 Individual Education Plan
Date of IEP
_______________
Yes
No
N/A
Progress Notes for Past Treatments
Date of PN
_______________
Yes
No
Short and Long Term Goals
Date of Goals _______________
Yes
No
For renewal of speech services progress notes and new goals are always required.
NOTES:
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