General Information For Authorization (Page 5 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.

Name: (Required)

Enter the last name, first name, and middle initial of the patient you are requesting

authorization for.

Client ID: (Required)

Enter the client ID - 9 numbers followed by WA.

For Prior Authorization (PA) requests when the client ID is unknown (e.g. client eligibility

pending):

 You will need to contact HCA at 1-800-562-3022 and the appropriate extension of

the Authorization Unit.

 A reference PA will be built with a placeholder client ID.

 If the PA is approved – once the client ID is known – you will need to contact HCA

either by fax or phone with the Client ID.

The PA will be updated and you will be able to bill the services approved.

Living Arrangements

Indicate where your patient resides such as, home, group home, assisted living, skilled

nursing facility, etc.

Reference Auth #

If requesting a change or extension to an existing authorization, please indicate the

number in this field.

Requesting NPI #: (Required)

The 10 digit number that has been assigned to the requesting provider by CMS.

Requesting Fax#

The fax number of the requesting provider.

Billing NPI #: (Required)

The 10 digit number that has been assigned to the billing provider by CMS.

Name

The name of the billing/servicing provider.

Referring NPI #

The 10 digit number that has been assigned to the referring provider by CMS.

Referring Fax #

The fax number of the referring provider.

Service Start Date

The date the service is planned to be started if known.

Description of service being

A short description of the service you are requesting (examples, manual wheelchair,

requested: (Required).

eyeglasses, hearing aid).

Serial/NEA or MEA#:

Enter the serial number of the equipment you are requesting repairs or modifications to

Required for all DME repairs.

or the NEA/MEA# to access the x-rays/pictures for this request.

Code Qualifier: (Required).

Enter the letter corresponding to the code from below:

T - CDT Proc Code

C - CPT Proc Code

D - DRG

P - HCPCS Proc Code

I - ICD - 9/10 Diagnosis Code

R - Rev Code

N - NDC - National Drug Code

S – ICD - 9/10 Proc Code

Enter each service code of the item you are requesting authorization that correlates to

National Code: (Required).

the Code Qualifier entered.

Modifier

When appropriate enter a modifier.

# Units/Days Requested:

Enter the number of units or days being requested for items that have a set allowable.

(Units or $ required).

(Refer to the program specific

Medicaid Provider Guide

for the appropriate unit/day

designation for the service code entered).

$ Amount Requested:

Enter the dollar amount being requested for those service codes that do not have a set

(Units or $ required).

allowable. (Refer to the program specific

Medicaid Provider Guide

and

fee schedules

for assistance) Must be entered in dollars & cents with a decimal (e.g. $400 should be

entered as 400.00).

Part # (DME only): (Required

Enter the manufacturer part # of the item requested.

for all requested codes).

HCA 13-835 (11/16)

General Information For Authorization Page 5

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