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 # ___________________