Kentucky Medicaid Mco Prior Authorization Request Form

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MAP 9 –MCO 012016
1
Kentucky Medicaid MCO
Prior Authorization Request Form
Check the box of the MCO in which the member is enrolled
 Anthem BCBS Medicaid
 Coventry Cares/Aetna Better Health  Humana – CareSource
 Passport Health Plan
 WellCare of Kentucky
Not all plans require PAs for the same services. Check with the plan before submitting
Please complete all appropriate fields
Failure to provide sufficient information will result in a delay in your request
Date ________________________ Time Faxed/Emailed ________________
Requesting Provider _________________________________ Telephone # ________________________ Fax #_________________
NPI # _____________________________________________
Type of Request
 Urgent Urgent is defined as ‘significant impact to health of member’  Non-Urgent
 Pre-Service  Post-Service  Concurrent  Emergent
Member Information
Member Name _________________________________ Medicaid ID # __________________ MCO ID# ______________
Date of Birth ___________________________________ Is member Pregnant?  Yes  No
Member’s PCP _________________________________ Phone __________________________ NPI ________________
Work-related injury?  Yes  No Motor Vehicle Accident related injury?  Yes  No
Does member have other insurance?  Yes  No Insurer _______________________ Medicare?  Part A  Part B
Servicing Provider Information
Servicing Provider ______________________________ NPI________________________ Tax ID# __________________
Address___________________________________________________________________________________________
City ________________________________________________ State _____________________ ZIP ________________
Phone ______________________________________________ Fax# _____________________
Are any supporting documents included?  Yes  No Number of Documents _____________
Type of Service
 Behavioral Health
 EPSDT
 Medical Care - Inpatient
 Radiology
 Behavioral Health - Inpatient
 Gastric By-pass
 Medical Care - Outpatient
 Substance Abuse
 Case Management
 Home Health
 Observation
 Surgical - Inpatient
 Dental Care
 Hospice
 OT/PT/ST
 Surgical - Outpatient
 DME Purchase
 Inhalation Therapy
 Oral Surgery
 Transportation
 DME Rental
 Maternity
 Private Duty Nursing
 Vision/Optometry
Clinical Information: Request MUST include medical documentation to be reviewed for medical necessity
 OTHER_______________________________________________________________________________________________________________
Primary ICD-10 Code ____________________________ Description __________________________________________
Dates of Service
Diagnosis
Requested
Procedure/
Requested Service
Code
Units/Visits
Start
Stop
Service Codes
Additional Information:
This form completed by ____________________________________________________ Phone # ___________________

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