Form Dhs 1144B PDF Details

In the intricate landscape of healthcare administration within the United States, particularly in the state of Hawaii, the Dhs 1144B form emerges as a critical document guiding the process of medical authorization under the Med-QUEST Division of the Department of Human Services. This particular form serves as a conduit through which requests for different types of medical services, specifically distinguishing between home infusion and non-home infusion (medication only) Prior Authorization (PA), are meticulously scrutinized and processed. The essence of the form is underscored by its stringent requirement for detailed information, including but not limited to, the Medicaid ID number, recipient's personal information, and specific service requested, thereby ensuring a comprehensive evaluation. Moreover, it highlights the importance of accurate and complete submissions, as any shortcomings directly impact the timely progression of the authorization process. Significantly, the form also delineates the conditional nature of payment approvals, which hinge on the patient's Medicaid eligibility and the provider's certification by Medicaid, emphasizing the need for providers to verify patient eligibility contemporaneously with service delivery. The issuing of authorization, which holds validity for 60 days post-approval, encapsulates a vital procedural step in facilitating access to necessary healthcare services for Medicaid recipients, yet it deliberately clarifies that it does not guarantee payment or endorse the fees charged, preserving the fiscal integrity of the Medicaid program.

QuestionAnswer
Form NameForm Dhs 1144B
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesDHS 1144B does california have medquest in sacramento form

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STATE OF HAWAII

Department of Human Services

Med-QUEST Division

ACS – Hawaii Sate Medicaid Fee for Service Program Attn: DUR, P.O. Box 967 Henderson, NC 27536-0967

REQUEST FOR MEDICAL AUTHORIZATION

Check only One – Different Types of Services Must Be Requested on Separate 1144B Forms. [ ] Home Infusion PA [ ] Non-home infusion (Medication only) PA

NOTE: INCOMPLETE FORM WILL DELAY THE AUTHORIZATION PROCESS. Approval of this request is not an authorization for payment or an approval of charges. Payment by the Medicaid Program is contingent on the patient being eligible and the provider of service being certified by Medicaid. The provider of service must verify patient eligibility at the time the service is rendered. Authorization expires 60 days from date of approval unless otherwise noted by the consultant.

1 Medicaid ID Number

 

 

2 Recipient’s Name (Last, First, M.I.)

 

 

 

 

 

 

 

3 Gender

 

4 Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[ ] M [

] F

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5 Medicare Coverage?

[

] Yes [ ] No

6 Currently at: [ ] Home

[ ] Hospital

[

] SNF/ICF/ICF-MR Facility

 

 

 

7 Expanded Early & Periodic

 

 

Is Patient receiving Medicare Home Health

Recipient’s Mailing Address

(St., City, Zip Code)

 

 

 

 

 

 

Screening Diagnosis & Treatment (EPSDT):

Benefits?

[ ] Yes

[

] No

 

 

 

 

 

 

 

 

 

[ ] Yes [

] No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician Section

 

 

 

 

 

 

Supplier Section (Circle Rent or Repair)

 

 

 

 

8 NDC Number or Drug Name, Strength, Units, Global Code, or HCPCS code

 

 

9 QTY

 

10 Purchase Price

11 Rent/Repair

 

12 Period Requested

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

From:

 

 

To:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician Section

 

 

 

 

 

 

 

 

13 Diagnosis or ICD-9 code

 

 

 

 

 

 

 

 

 

14 BMI (for anorexiants):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15 Period Requested

 

 

16 Prognosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17 Justification (include history of previous treatment) ([ ] Attachment)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18Print Prescriber’s Name/Mailing Address

19Prescriber’s Signature

20 Prescriber’s NPI

21 Date

 

 

22Telephone #

23 Fax #

24 Contact Name

 

 

25 Print Supplier’s Name/Mailing Address

Supplier Section

26Comments

27

Contact Name

28

Telephone #

29

Fax #

 

 

 

 

 

 

 

 

30

Supplier’s Signature

31

Supplier’s NPI

32

Date

 

 

 

 

 

 

 

 

DHS 1144B (Rev. 03/07)