Prior Authorization Form (Pa-14) Unisys / La. Medicaid
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1
2MAIL TO:
STATE OF LOUISIANA
UNISYS / 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 #
14 – EPSDT PERSONAL
(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) PRESCRIPTION DATE
PRIMARY CODE
( MMDDYYYY)
STATUS CODES:
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
PERSONAL CARE SERVICE
REQUESTED
AUTHORIZED
STATUS
P.A. MESSAGE/
CODE
EACH 15 MINUTES
UNITS
UNITS
DENIAL CODE (S)
(13)
COMMENTS:
PROVIDER NAME: ____________________________________________________________________
ADDRESS: ___________________________________________________________________________
CITY: _______________________________________ STATE: ___________ZIPCODE _____________
TELEPHONE: ( ______) _______ __________ FAX NUMBER: (_______) _______ ___________
(14)
(15)
PROVIDER SIGNATURE: ____________________________________________________ DATE OF REQUEST: __________________________
Revised PA-14 FORM
Issued 10/1/2015
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Parent category: Medical