Prior Authorization Form (Pa-14) Unisys / La. Medicaid Page 2
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2Instructions For Completing Prior Authorization Form (PA-14)
NOTE: ONLY THE FIELDS LISTED BELOW ARE TO BE COMPLETED BY THE PROVIDER OF SERVICE. ALL OTHER
FIELDS ARE TO BE USED BY THE PRIOR AUTHORIZATION DEPARTMENT AT UNISYS.
FIELD NO. 2
ENTER RECIPIENT’S 13-DIGIT MEDICAID ID NUMBER OR THE 16-DIGIT CCN NUMBER.
FIELD NO. 3
ENTER THE RECIPIENT’S SOCIAL SECURITY NUMBER.
FIELD NO. 4
ENTER THE RECIPIENT’S LAST NAME, FIRST NAME AND MIDDLE INITIAL AS IT APPEARS ON THE
RECIPIENT’S MEDICAID CARD.
FIELD NO. 5
ENTER THE RECIPIENT’S DATE OF BIRTH IN MMDDYYYY FORMAT (MM=MONTH, DD=DAY,
YYYY=YEAR).
FIELD NO. 6
ENTER THE PROVIDER’S 7-DIGIT MEDICAID NUMBER.
FIELD NO. 7
ENTER THE FIRST DAY THE SERVICE IS REQUESTED TO START AND THE LAST DAY OF SERVICE
FOR THAT INDIVIDUAL TREATMENT PLAN IN MMDDYYYY FORMAT (MM=MONTH, DD=DAY,
YYYY=YEAR.
FIELD NO. 8
PLACE A CHECK MARK IN THE ‘YES’ OR ‘NO’ BOX TO INDICATE WHETHER OR NOT THE RECIPIENT
IS CURRENTLY RECEIVING SERVICES.
FIELD NO. 9
ENTER THE DIAGNOSIS CODES (PRIMARY & SECONDARY).
FIELD NO. 10
ENTER THE DAY THE PRESCRIPTION, DOCTOR’S ORDERS WAS WRITTEN IN MMDDYYYY FORMAT
(MM=MONTH, DD=DAY, YYYY=YEAR)
FIELD NO. 11
ENTER THE NAME OF THE RECIPIENT’S ATTENDING PHYSICIAN PRESCRIBING THE SERVICES.
FIELD NO. 12
ENTER THE HCPCS CODE.
FIELD NO. 12A
ENTER THE CORRESPONDING MODIFIER (WHEN APPROPRIATE).
FIELD NO. 12B
ENTER THE HCPCS CODE’S CORRESPONDING DESCRIPTION FOR EACH PROCEDURE REQUESTED.
FIELD NO. 12C
ENTER THE NUMBER OF TIMES THE REQUESTED PROCEDURE WILL BE PERFORMED DURING THE
TREATMENT PLAN. CALCULATE THE TOTAL UNITS REQUESTED BY MULTIPLYING THE NUMBER OF
UNITS PER DAY (1 UNIT = 15 MINUTES) TIMES THE NUMBER OF DAYS PER WEEK TIMES THE
NUMBER OF WEEKS COVERED IN THE TREATMENT PLAN. THIS WILL GIVE THE TOTAL UNITS
REQUESTED. BELOW ARE TWO EXAMPLES ON THE PROPER WAY TO CALCULATE THE TOTAL
UNITS REQUESTED:
EXAMPLE 1) REQUESTING FOUR-HOURS PER DAY FOR A SIX MONTH PERIOD:
4 HOURS PER DAY = 16 UNITS PER DAY, 7 DAYS A WEEK, 26 WEEKS =
16 X 7 X 26 = 2912 TOTAL UNITS REQUESTED
EXAMPLE 2) REQUESTING TWO-HOURS PER DAY ON WEEKENDS AND FOUR-HOURS PER DAY ON
WEEKDAYS:
2 HOURS PER DAY (WEEKENDS) = 8 UNITS PER DAY, 2 DAYS A WEEK, 26 WEEKS =
8 X 2 X 26 = 416 TOTAL UNITS REQUESTED FOR WEEKENDS
4 HRS. PER DAY (WEEKDAYS) = 16 UNITS PER DAY, 5 DAYS A WEEK, 26 WEEKS =
16 X 5 X 26 = 2080 TOTAL UNITS REQUESTED FOR WEEKDAYS
THE TOTAL UNITS REQUESTED WOULD BE THE COMBINATION OF THE TOTAL WEEKEND
UNITS (416) AND WEEKDAY UNITS (2080), WHICH WOULD EQUAL TO 2496 TOTAL UNITS
REQUESTED. THIS IS THE NUMBER (2496) TO ENTER IN FIELD NUMBER 12C.
FIELD NO. 13
ENTER THE NAME, MAILING ADDRESS AND TELEPHONE NUMBER OF THE PROVIDER OF SERVICE.
FIELD NO. 14
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. 15
DATE IS REQUIRED. YOUR 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 UNISYS.
PRIOR AUTHORIZATION PCS DEPARTMENT TOLL-FREE NO. IS 1-800-807-1320
PRIOR AUTHORIZATION FAX NO. IS 1-225-237-3342
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