Prior Authorization Form (Pa-16) - Molina / La. Medicaid
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1
2MAIL TO:
STATE OF LOUISIANA
MOLINA / LA. MEDICAID
DEPARTMENT OF HEALTH AND HOSPITALS
P.O. BOX 14919
Bureau of Health Services Financing Medical Assistance Program
BATON ROUGE, LA. 70898-4919
REQUEST FOR PRIOR AUTHORIZATION
P.A. NUMBER
FAX TO: (225) 216-6342
CONTINUATION OF SERVICES _____YES _____ NO
(1) PRIOR AUTHORIZATION TYPE:
(2) RECIPIENT 13-DIGIT MEDICAID ID NUMBER OR 16-DIGIT CCN NUMBER
(3) SOCIAL SECURITY #
16– PEDIATRIC DAY HEALTH
(4) RECIPIENT LAST NAME
FIRST NAME
MI
(5) DATE OF BIRTH
CARE SERVICES
(7) SERVICE TREATMENT PLAN
(8) IS RECIPIENT CURRENTLY
P. A. NURSE AND / OR PHYSICIAN
(6) MEDICAID PROVIDER NUMBER
BEGIN DATE
END DATE
RECEIVING THESE SERVICES REVIEWER’S SIGNATURE: & DATE
( 7- DIGIT)
(MMDDYYY)
(MMDDYYY)
_______ YES
_______ NO
(9) DIAGNOSIS:
(10) PHYSICIAN’S ORDER
PRIMARY CODE
DATE
STATUS CODE:
( MMDDYYYY)
2= APPROVED
3= DENIED
SECONDARY CODE
(11) PRESCRIBING PHYSICIAN’S NAME AND/ OR NUMBER:
DESCRIPTION OF SERVICES
FOR INTERNAL USE ONLY
(12)
(12A)
(12B) DESCRIPTION
(12C)
PROCEDURE
MODIFER
PEDIATRIC DAY HEALTH CARE
REQUESTED
AUTHORIZED
STATUS
P.A. MESSAGE/
SERVICES
CODE
UNITS
UNITS
DENIAL CODE (S)
_____________________________________________________________________________________________________________________________
(13) Brief Medical History:
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
(14) Current Status:
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
(15) Physician’s orders/treatment Plan (Provide Frequency, Duration, and Provider Type for services requested:
_____________________________________________________________________________________________________________________________
) CASE MANAGER INFORMATION
(16)
(17
:
PROVIDER NAME
: _________________________________________________ NAME: ______________________________________________________________
ADDRESS: _________________________________________________________ ADDRESS: ____________________________________________________________
CITY: _____________________ STATE: __________ZIPCODE ______________ CITY: ___________________________STATE: _______ZIPCODE: ____________
TELEPHONE: ( ____) _____ ______ FAX NUMBER: (_____) _____ _______ TELEPHONE: (____) _____ ________ FAXNUMBER: (____) ______ __________
18)
(19)
(
PROVIDER SIGNATURE: ____________________________________________________ DATE OF REQUEST: __________________________
Revised PA-16 Form
Issued 10/1/2015
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