General Information For Authorization (Page 3 of 7) in pdf

General Information For Authorization Page 3

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

FIELD

NAME

ACTION

ALL FIELDS MUST BE TYPED.

Service Type (Required)

If you selected “504 – Home Health” for field #1, please select one of the following

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codes for this field:

ERSO

for ERSO-PA

MISC

for Miscellaneous

for Home Health

for Therapies (PT / OT / ST)

If you selected “505 – Hospice” for field #1, please select one of the following codes for

this field:

ERSO

for ERSO-PA

HSPC

for Hospice

MISC

for Miscellaneous

If you selected “506 – Inpatient Hospital” for field #1, please select one of the following

codes for this field:

for Bariatric Surgery

for Readmission

ERSO

for ERSO-PA

for Surgery

OOS

for Out of State

TNP

for Transplants

for Other

VNSS

for Vagus Nerve Stimulator

PAS

for PAS

MISC

for Miscellaneous

If you selected “508 – Medical” for field #1, please select one of the following codes for

this field:

BSS2

for Bariatric Surgery Stage 2

for Neuro-Psych

BTX

for Botox

OOS

for Out of State

CIERP for Cochlear Implant

PSY

for Psychotherapy

Exterior Replacement Parts

SYN

for Synagis

for Cardiac Rehab

for Therapies (PT/OT/ST)

ERSO

for ERSO-PA

for Transportation

HEA

for Hearing Aids

for Vision

for Infusion / Parental

VST

for Vest

Therapy

for Vision Therapy

for Medications

MISC

for Miscellaneous

If you selected “509 – Medical Nutrition” for field #1, please select one of the following

codes for this field:

for Enteral Nutrition

for Medical Nutrition

MISC

for Miscellaneous

If you selected “511 – Output Proc/Diag” for field #1, please select one of the following

codes for this field:

CCTA

for Coronary CT Angiogram

OOS

for Out of State

for Cochlear Implants

OTRS

for Other Surgery

ERSO

for ERSO-PA

PSCN

for PET Scan

GCK

for Gamma/Cyber Knife

for Other

for Genetic Testing

for Surgery

for Hyperbaric Oxygen

SCAN

for Radiology

for Hysterectomy

MISC

for Miscellaneous

MRI

for MRI

If you selected “513 – Physical Medicine & Rehabilitation (PM & R)” for field #1,

please select one of the following codes for this field:

ERSO

for ERSO-PA

PMR

for PM and R

MISC

for Miscellaneous

HCA 13-835 (11/16)

General Information For Authorization Page 3

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