Dphhs-Sltc-124 Home Health Initial Authorization Request Form printable pdf download

DPHHS-SLTC-124

STATE OF MONTANA

(Rev. 05/05)

Department of Public Health and Human Services

HOME HEALTH SERVICES

REQUEST FOR INITIAL AUTHORIZATION

Recipient Name: ____________________________________________________________

DOB: ___________________________

Address: ___________________________________________________________________________________ County ____________

Medicaid #: ___________________________________________

Medicare #: ___________________________________________

Is this recipient under Passport? ________ Passport MD:______________________________ MD Phone:_____________________

Requesting Agency: _____________________________________________________ Contact: ________________________________

Provider Number: ____________________ City: _____________________________________ Phone: ________________________

Date services to be initiated: __________________________________________________

Does the recipient have primary insurance coverage: __________________________________________________________________

_______________________________________________________________________________________________________________

Has service been denied from primary insurer (provide copy): __________________________________________________________

_______________________________________________________________________________________________________________

Diagnosis:

If dually eligible, in detail explain why recipient does not qualify for the Medicare benefit: __________________________________

_______________________________________________________________________________________________________________

Type of prior authorization requested (July to June):

______ To provide 1 - 75 skilled nursing visits per state fiscal year.

______ To provide 1 - 100 combined therapy (PT, ST, OT) visits per state fiscal year.

______ To provide __________ home health aide visits.

Synopsis of services (includes frequency, duration and anticipated outcome):

Signature: __________________________________________________ Date: ___________________ Phone: ___________________

FOUNDATION USE ONLY

Approved ________

Denied ________

Comments:

Reviewer Signature: _____________________________________________________________ Date: _________________________

Note: If services in excess of above limits are required, prior authorization must be requested from the Mountain Pacific Quality

Health Foundation on form DPHHS-MA-125, Request for Prior Authorization for Extended Services.

Fax all Home Health requests to:

1-800-413-3890

Dphhs-Sltc-124 Home Health Initial Authorization Request Form