Medicaid Medical Surgical Prior Authorization Request

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Medical/Surgical
Medicaid
Prior Authorization Request
Requires Trillium
Medically Urgent
Phone: 541-485-2155
Fax: 541-485-0737
Medicare PA also
Instructions for Completion:
• Please print clearly. When complete, fax to 541-485-0737.
• Complete all boxes marked with * - requests with incomplete * areas will be returned without processing.
• Attach clinical notes, lab results, imaging results, etc., to support request.
*Date
*Office Contact Person
*Phone #
*Fax #
*Member ID#
*Member Name
*DOB
Member Phone #
*Ordering M.D.
*Primary Care Provider
Workers Comp
Accident/Injury
Other Insurance ID#
Effective Date
Plan
Subscriber
Related
Retro Request
Medical / Surgical Request
*
Co-surgeon / Assistant
Inpatient
SNF
*Providing Facility
*Requested Dates of Service
Outpatient
ICF PT/OT/ST
Enteral
Home Health
to
Home Infusion, non-enteral
*Dx codes pertinent to this
*Code Description
request
1.
.
2.
.
3.
.
4.
.
*CPT / HCPCS / R-Codes
*Code Description
Quantity Requesting
1.
2.
3.
4.
5.
6.
7.
For Insurance Use Only
Referral #
Status:
 Approved  Denied
 Office Contacted
___________________________________
Comments:
Effective Date
___________________ to __________________
DxCode ______________________________
____________________________________________________________________________________________
Medical Director or Designee
Date
# of Visits _______
Scope __________
Approval is not a guarantee of payment. Benefit eligibility must be in effect at the time services are rendered and all plan provisions will apply.
CONFIDENTIALITY: The documents accompanying this transmission contain information belonging to Trillium Community Health Plan which is confidential and/or legally privileged. The
information is intended only for the use of the individual or entity named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or
taking of any action in reliance on the contents of this telecopied information is strictly prohibited. If you have received this document in error, please immediately notify us by telephone
and destroy the documents received. Thank you.
8/29/12

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