Inpatient Medicaid Prior Authorization Fax Form - Peach State Health Plan

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INPATIENT MEDICAID

Complete and Fax to:1-866-532-8834

PRIOR AUTHORIZATION FAX FORM

Elective Request

Urgent Request - I certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within 48 hours to

avoid complications and unnecessary suffering or severe pain.

URGENT REQUESTS MUST BE SIGNED BY THE

REQUESTING PHYSICIAN TO RECEIVE PRIORITY.

INDICATES REQUIRED FIELD

Date of Birth

MEMBER INFORMATION

(MMDDYYYY)

Member ID/Medicaid ID

Last Name, First

REQUESTING PROVIDER INFORMATION

Requesting NPI

Requesting TIN

Requesting Provider Contact Name

Requesting Provider Name

Phone

Fax

SERVICING PROVIDER / FACILITY INFORMATION

Same as Requesting Provider

Servicing NPI

Servicing TIN

Servicing Provider Contact Name

Servicing Provider/Facility Name

Phone

Fax

AUTHORIZATION REQUEST

Primary Procedure Code

Start Date OR Admission Date

Diagnosis Code

(MMDDYYYY)

(ICD-10)

(CPT/HCPCS)

(Modifier)

Discharge Date (if applicable) otherwise

Additional Procedure Code

Length of Stay will be based on Medical Necessity

(CPT/HCPCS)

(Modifier)

(MMDDYYYY)

INPATIENT SERVICE TYPE

(Enter the Service type number in the boxes)

Delivery

970

Medical

779

C-Section

402

Skilled Nursing Facility

720

Vaginal Delivery

411

Surgical

Transplant

929

Hospice Inpatient

209

Surgery

Inpatient Rehab

419

Work-up

479

Inpatient Hospital

220

Comprehensive Inpatient

Rehab Facility

ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED.

COPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION.

Disclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Benefit and medically necessary with prior

authorization as per Plan policy and procedures.

Confidentiality: The information contained in this transmission is confidential and may be protected under the Health Insurance Portability and Accountability Act of 1996. If you are not the

Rev. 01 13 2016

GA-PAF-0677

intended recipient any use, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and destroy this document.