Psychological Services Request For Prior Authorization Page 2
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1
2INSTRUCTIONS FOR COMPLETION
HEADER INFORMATION
Participant Name, Number and Date of Birth – Enter the participant’s information as it appears on the MO HealthNet
ID card.
Provider Name – Enter the provider name.
Billing Provider Identifier – Enter the provider identifier (NPI) that will be used for billing services to MO HealthNet. If
this is a clinic/group setting the clinic number should be entered here.
Provider Taxonomy Code – Enter the Taxonomy code (if required)
Provider Telephone Number – Enter current telephone number of the provider making the request.
Provider Fax Number – Enter the fax number of the provider making the request.
Signature/Date – The provider of services should sign the request and indicate the date the form was completed.
*Number of Hours used on current PA – If the current PA was approved for less than 10 hours, a continued treatment
request can be made when 40% of the existing PA hours have been used. If the current PA was approved for 10 hours
or more, the continued treatment request can be made when 75% of the existing PA hours have been used.
QUESTIONS NUMBER 1 THROUGH 7 MUST BE COMPLETED FOR THERAPIES REQUESTED.
Requested Start Date of PA – Please indicate the date you would like for your PA to begin. NOTE: The authorized start
is the date of receipt or noted subsequent date.
Hours requested for Assessment and Diagnostic Testing must be noted in order to be authorized. Individual Interactive
Therapy, Family Therapy Without the Patient Present, and all services for children ages birth through 2 years of age require
documentation at all times.
**REMINDER: When requesting Family Therapy, please list all members of the family. Only one (1) PA will be approved
and open at a time for Family Therapy. If there is more than one eligible child and no child is exclusively identified as the
primary patient of treatment, then the oldest child’s DCN MUST be used for PA and billing purposes. PROVIDERS
SHOULD NOT REQUEST MORE THAN ONE (1) FAMILY THERAPY PRIOR AUTHORIZATION PER FAMILY. Each child
may not be seen separately with parents and billed as Family Therapy.
If therapy is the result of a court order a copy should be kept in the patient’s file and a copy of the court order should be
forwarded along with any continued therapy request.
DSM-IV-TR MULTIAXIAL ASSESSMENT MUST BE COMPLETED
Axis I – Clinical Disorders
Axis II – Personality Disorders, Mental Retardation
Axis III – General Medical Conditions
Axis IV – Psychosocial and Environmental Problems
Axis V – Global Assessment of Functioning
Prior authorization request may be phoned, faxed or mailed into the call center (see below)
InfoCrossing
P.O. Box 4800
Jefferson City, MO 65102
Phone (toll free) 866-771-3350
Fax 573-635-6516
AN APPROVED AUTHORIZATION APPROVES ONLY THE MEDICAL NECESSITY OF THE SERVICE AND DOES NOT
GUARANTEE PAYMENT.
MO 886-4140 (6-08)
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