Ancillary Service Authorization Request printable pdf download

Ancillary Service Authorization Request

Western Oregon Advanced Health, LLC.

P.O. Box 1096, Coos Bay, OR 97420

Voice: 541-269-7400 • 800-264-0014

Fax: 541-269-7147 • TTY: 877-769-7400

Instructions to Complete Ancillary Service Authorization Request

For Durable Medical Equipment (DME) or Oral Enteral Supplements

Provider is responsible to submitting all information in the top area of the form.

This form is used for submitting prior authorization requests only. For Referral/PA physician services

use the “Physician Referral/Prior Authorization Request” form.

Required Documentation:

DME:

♦ DME requiring Certificates of Medical Necessity (CMN’s) can be submitted with the

dispensing RX. The request will be pended waiting the receipt of CMN or other information

as requested.

Oral Enteral Supplements:

♦ Criteria letter must be submitted with request as well as the prescription. Units submitted

must be in calories, not cans per day.

Disclaimer: Approval does not assure payment, which also depends on patient eligibility on date of

service, contract terms, and compliance with rules, regulations and policies of WOAH and/or OHA as

applicable.

Fax completed form and documentation to WOAH’s Medical Management Department at (541) 269-

7147.

If you have questions regarding this form or other related questions, please contact WOAH’s

Medical Management Department at (541) 269-7400.

To complete form, please follow these instructions:

Performing Provider:

Enter the name of the provider that is submitting the request

Phone #:

Enter the phone of the requesting provider

Fax #:

Enter the fax number of the requesting provider

Member Name:

Enter the full name of the OHP Member, including middle initial,

if known

Member ID#:

(Required field) Enter the Member’s WOAH ID#

DOB:

(Required field) Enter the Member’s date of birth

Prescribing Provider:

Enter the physician who prescribed the equipment

PCP:

Enter the PCP for the WOAH member, if known. Leave blank if

unknown.

Requested Dates:

Enter the requested dates to provide equipment or services.

ICD-10 Code(s):

(Required field > 10-01-2015) Enter the ICD-10 codes for the

diagnosis (es) that are related to the service being requested.

Diagnoses must be coded to the highest level of specificity.

Item/Service Requested:

Enter the description of the item. (e.g. pant liners)

Ancillary Service Authorization Request

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