Prior Authorization Form (Pa-16) - Molina / La. Medicaid Page 2
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2Instructions for Completing Prior Authorization Form (PA-16)
Note: Only the field list below is to be completed by the Provider of Service. All other fields are to be used by the Prior Authorization Department at
Molina.
FIELD NO 2
Recipient Medicaid ID - Enter the 13 digit Medicaid ID number or The 16 Digit CCN Number.
FIELD NO 3
Social Security Number - Enter the recipient’s social security number.
FIELD NO 4
Recipient Name – Enter recipient’s last name, first name, and middle initial
FIELD NO 5
Date of Birth – Enter recipient’s date of birth in MMDDYYYY Format (MM=Month, DD=Day, YYYY=Year).
FIELD NO 6
Medicaid Provider Number - Enter the 7 digit assigned to you by Medicaid
FIELD NO 7
Service Treatment Plan – This identifies the period covered by the Plan of Care. Enter the dates in MMDDYYYY
Format (MM=Month, DD=Day, YYYY=Year).
FIELD NO 8
Is Recipient currently receiving these services? Place a checkmark in the ‘Yes’ or ‘No’ Box to indicate whether or
not the recipient is currently receiving services.
FIELD NO 9
Diagnosis – Primary Code. Enter a valid diagnosis code and condition which best describes the
principal reason for Pediatric Day Health Care. If more than one diagnosis is treated concurrently, enter the
diagnosis that represents the most acute condition and requires the most intensive services.
Diagnosis – Secondary Code. Enter a valid diagnosis code and condition relevant to the care rendered.
Place in order of seriousness to justify the discipline and services being rendered. Other pertinent diagnoses are conditions
that coexisted at the time the plan of care was established or developed subsequently.
FIELD NO 10
Physician’s Order Date – Enter the date the Physician’s Order was written in MMDDYYYY Format (MM=Month,
DD=Day, YYYY=Year).
FIELD NO 11
Prescribing Physician’s Name and/or Number – Enter the name of the recipient’s attending physician prescribing
the services and the physician’s NPI
number.
FIELD NO 12
Procedure Code – Enter the HCPCS Code.
FIELD NO 12A
Modifier – Enter the corresponding modifier (when appropriate).
FIELD NO 12B
Description – Enter the HCPCS code’s corresponding description for each procedure requested
FIELD NO 12C
Requested Units - Reimbursement for PDHC services shall be a statewide fixed per diem rate which is based on
the number of hours that a qualified recipient attends the PDHC facility.
For Full Day of Service, the Procedure Code T 1025 will be used for more than four hours but doesn’t exceed
12 hours per day. Calculate the total units requested by multiplying the full day per diem by the number of days
per week times the number of weeks covered in the treatment plan. This will give the total units requested.
Example- Procedure Code T 1025 - 1 full day of service X 7 days a week x 26 weeks = 182 units requested.
For a Partial Day of Service, the Procedure Code T 1026 will be used for services four hours or less per day,
Calculate the total units requested by multiplying the number of hours per day by the number of days per week
times the number of weeks covered in the treatment plan. This will give the total units requested.
Example - Procedure Code T 1026 - 4 hours per day x 7 days a week x 26 week = 728 units requested.
FIELD NO 13
Brief Medical History – Provide a brief summary of recipient’s medical history that best describes the need for PDHC.
FIELD NO 14
Current Status –Describe recipient’s current medical status (examples -chronic, remission, stable, etc.)
FIELD NO 15
Physician’s orders/treatment Plan – Provide the Frequency, Duration, and Provider Type for services requested.
FIELD NO 16
Provider Name – Enter the name, mailing address, telephone and fax number of the Provider of Service.
FIELD NO 17
Case Manager Information – Enter the name, mailing address, telephone and fax number of Case Manager.
FIELD NO 18
Provider Signatures - Provider/Authorized Signature is required. Your request will not be accepted if not
signed. If using a stamped signature, it must be initialed by authorized personnel.
FIELD NO 19
Date of Request – The date is required and request will not be accepted if field is not dated.
If you have any questions concerning the Prior Authorization Process, please contact the Prior Authorization
Department at Molina.
Prior Authorization PDHC Department Toll Free Number is 1-800-807-1320.
Prior Authorization Fax Number is 1-225-216-6342.
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