Medicaid prior authorization is a process that requires health care providers to get approval from the state Medicaid program before providing certain services or drugs to their patients. This tutorial will provide an overview of how to complete a Medicaid prior authorization request form. It includes information on what services need prior authorization, what documentation is needed, and how to submit the request. Care providers who want to ensure they are providing the best possible care for their patients should be familiar with Medicaid prior authorization requirements. The form is fairly straightforward and can be easily completed with the required documentation. Providers who have any questions about the process can contact their state Medicaid office for more help.
| Question | Answer |
|---|---|
| Form Name | Care Prior Authorization Request Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | molina centennial prior authorization form, presbyterian centennial care prior authorization form, new mexico medicaid prior authorization form, blue cross blue shield centennial care prior authorization |
New Mexico Medicaid Managed Care
Prior Authorization Request Form
Request Date:
BCBS |
Molina |
Presbyterian |
United Healthcare |
Outpatient FAX: (505) |
Long Term Care FAX: (505) |
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Inpatient FAX: (505) |
UNM FAX: (505) |
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Phone: (505)
Routine
Urgent or Expedited Initial Determination
For a Prior Authorization request to be considered “Urgent” or “Expedited,” the request must include a provider’s order stating that waiting for a decision under a standard timeframe could endanger the member’s life, health, or ability to regain maximum functionality or would cause serious pain. Provider’s signature below is an attestation that this request meets expedited/urgent criteria listed here.
Practitioner Signature: |
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(Required for Urgent or Expedited requests) |
Member Information: Complete the information below and attach all of the clinical information pertinent to the request.
Member Name:
Other Carrier:
ID Number: |
DOB: |
Policy/ID #: |
Phone No. |
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Provider Information
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Requesting Provider: |
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Phone: |
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Fax: |
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Servicing Provider/Facility: |
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Phone: |
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Fax: |
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Servicing Provider/Facility Address: |
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Tax ID/NPI #: |
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New/Initial Request |
Ongoing Care |
Previous Authorization Number: |
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DME/Prosthetic/Orthotic |
Ambulatory/Outpatient Surgery |
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Office |
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Home Birth |
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Inpatient LOS: |
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Facility: |
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PT/OT/ST Practitioner’s |
Order Attached |
Clinical Information Attached |
Other: |
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Diagnosis(es) |
_________ |
_________ |
_________ _________ |
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Procedure (Must match CPT code/s):________________________________________________________
Procedure(s) (CPT/HCPC) (Required): _________ _________ _________ _________ _________
Requested Effective Date: ___________ |
End Date: ___________ |
Number of Visits/Units: ________ |
Please attach all supporting clinical information to include symptoms, past medical history, diagnostic testing, conservative treatment prior to request.
Services requested. Submit all relevant clinical data to support the request for services. Failure to provide supporting documentation will delay processing and may result in a denial.
For Health Plan Use ONLY: (this would be to communicate authorization information)
[MPC121322] |
[CENTENNIAL CARE # 389] |