General Information For Authorization (Page 2 of 7) in pdf

Instructions to fill out the General Information for Authorization form, HCA 13-835

FIELD

NAME

ACTION

ALL FIELDS MUST BE TYPED.

Org (Required)

Enter the Number that Matches the Program/Unit for the Request

501 – Dental

502 – Durable Medical Equipment (DME)

504 – Home Health

505 – Hospice

506 – Inpatient Hospital

508 – Medical

509 – Medical Nutrition

511 – Outpt Proc/Diag

513 – Physical Medicine & Rehabilitation (PM & R)

514 – Aging and Long-Term Support Administration (ALTSA)

518 – LTAC

519 – Respiratory

521 – Maternity Support/Infant Case Management

524 – Concurrent Care

525 – ABA Services

526 – Complex Rehabilitation Technology (CRT)

527 – Chemical-Using Pregnant (CUP) Women Program

Service Type (Required)

Enter the letter(s) in all CAPS that represent the service type you are requesting.

If you selected “501 – Dental” for field #1, please select one of the following codes for

this field:

ASC

for ASC

for In-Patient

CWN

for Crowns

ODC

for Orthodontic

DEN

for Dentures

OUTP

for Out-Patient

for Denture/Partial

PSM

for Perio-Scaling/Maintenance

ERSO

for ERSO-PA

PTL

for Partial

EXT

for Extractions

RBS

for Rebases

EXTD

for Extractions w/Dentures

RLNS

for Relines

for General Anesthesia

for Transfer Case

GAE

for General Anesthesia

MISC

for Miscellaneous

w/ extractions

If you selected “502 – Durable Medical Equipment (DME)” for field #1, please select

one of the following codes for this field:

for Ambulatory Aids

for Orthopedic Shoes

for Bath Bench

OTC

for Orthotics

BEM

for Bath Equipment (misc.)

for Ostomy Products

BGS

for Bone Growth Stimulator

ODME for Other DME

for Breast Pump

OTRR

for Other Repairs

for Commode

for Patient Lifts

for Compression Garments

PWH

for Power Wheelchair - Home

CSC

for Commode/Shower Chair

PWNF for Power Wheelchair – NF

DTS

for Diabetic Testing

PWR

for Power Wheelchair Repair

Supplies (See Pharmacy

PRS

for Prone Standers

Billing Instructions for POS

PROS

for Prosthetics

Billing)

for Room Equipment

ERSO

for ERSO-PA

for Shower Chairs

FSFS

for Floor Sitter/Feeder Seat

SBS

for Specialty “Beds/Surfaces

for Hospital Beds

SGD

for Speech Generating Devices

for Hospital Cribs

for Standing Frames

for Incontinent Supplies

STND

for Standers

MWH

for Manual Wheelchair -

for TENS Units

Home

for Urinary Supplies

MWNF for Manual Wheelchair – NF

WDCS for VAC/Wound - decubiti supplies

MWR

for Manual Wheelchair

MISC

for Miscellaneous

Repair

HCA 13-835 (11/16)

General Information For Authorization Page 2

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