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
X
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.