General Information For Authorization (Page 4 of 7) in pdf

General Information For Authorization Page 4

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

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field #1, please select one of the following codes for this field:

PDN

for Private Duty Nursing

MISC

for Miscellaneous

If you selected “518 – LTAC” for field #1, please select one of the following codes for

this field:

ERSO

for ERSO-PA

LTAC

for LTAC

for Other

If you selected “519 – Respiratory” for field #1, please select one of the following codes

for this field:

CPAP

for CPAP/BiPAP

OXY

for Oxygen

ERSO

for ERSO-PA

SUP

for Supplies

NEB

for Nebulizer

VENT

for Vent

OXM

for Oximeter

for Other

If you selected “521 – Maternity Support/Infant Case Management (MSS)” for field

#1, please select one of the following codes for this field:

ICM

for Infant Case Management

for Post Pregnancy Only

PPP

for Prenatal/Post Pregnancy

for Other

If you selected “524 – Concurrent Care” (for children on Hospice) for field #1, please

select one of the following codes for this field:

for Concurrent Care Services

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

selected “525 – ABA Services” for field #1, please select one of the following codes for

this field:

for In Home/Community/Office

DAYP

for Day Program

If you selected “526 – Complex Rehabilitation Technology” (CRT) for field #1, please

select one of the following codes for this field:

ERSO for ERSO-PA

PWH

for Power Wheelchair - Home

MWH

for Manual Wheelchair - Home

PWNF for Power Wheelchair – NF

MWNF for Manual Wheelchair - NF

PWR

for Power Wheelchair Repairs

MWR

for Manual Wheelchair Repairs

PWS

for Power Wheelchair Supplies

MWS

for Manual Wheelchair Supplies

If you selected “527 – Chemical-Using Pregnant (CUP) Women Program” for field #1,

please select one of the following codes for this field:

for Detox

for Detox/Medical Stabilization

for Medical Stabilization

HCA 13-835 (11/16)

General Information For Authorization Page 4

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