Wv Medicaid Prior Authorization Form (Chiropractic)

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WV MEDICAID PRIOR AUTHORIZATION FORM
FAX 1-844-633-8431 CHIROPRACTIC
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:
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: Office
List ICD Diagnosis Code(s):
Primary ICD DX: ____________________________________________________________________________________________________________
Symptoms: ________________________________________________________________________________________________________________
Other DX:
CPT/Service Code(s) Requested:
START DATE_________________________
______________|_______________|_______________
Are the physician orders for each code attached? ___Yes ___No
If No, please list why:
Patient Status:
Established
New Period of Request:
30 Days
60 Days
90 Days

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