Form Mo 886 0858 PDF Details

At the heart of ensuring the accessibility and provision of necessary healthcare services within Missouri's healthcare system lies the MO 886 0858 form—an essential document that navigates the complex process of prior authorization for healthcare providers and participants. This form, as dictated by the Missouri Department of Social Services, serves multiple critical functions: from validating the medical necessity of specific services or equipment to guiding healthcare practitioners through the meticulous procedure of submitting requests. The MO 886 0858 form is meticulously structured to cover all requisite information such as the participant’s general details, the medical justification for the requested service or item, and details concerning the healthcare provider and the prescribing or performing practitioner. It highlights the importance of detailed medical necessity explanations for services, equipment, procedures, or prostheses, underscoring that authorization is a prerequisite that assures the need for a service, yet does not guarantee payment. Furthermore, this form is a key component in navigating Missouri's healthcare system, emphasizing eligibility on the service date or when equipment is received, and thereby assisting in the efficient and effective facilitation of health services to Missouri's HealthNet participants. Instructions provided on the form underscore the requirement for precision and completeness in the submission process, thereby streamlining approvals and ensuring the expedited delivery of healthcare services to those in need.

QuestionAnswer
Form NameForm Mo 886 0858
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmissouri medicaid opioid prior authorization form, missouri prior authorization request form, missouri medicaid medication prior authorization form, online missouri medicaid medication forms

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missouri department of social services

 

 

 

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return to: infocrossing healthcare services, inc.

 

 

mo healthnet division

 

 

 

 

 

 

 

po box 5700

 

 

 

PRIOR AUTHORIzATION REQUEST

 

 

 

 

Jefferson city, mo 65102

authorization approves the medical necessity of the requested service only. it does not guarantee payment, nor does it guarantee that the

amount billed will be the amount reimbursed. the participant must be mo healthnet eligible on the date of service or date the equipment or

prosthesis is received by the participant. SEE REVERSE SIDE FOR INSTRUCTIONS.

 

 

 

 

I.  GENERAL INFORMATION

 

 

 

2.  name (last, first, m.i.)

 

 

 

 

3.  date of birth

1.

 

 

 

 

 

 

 

 

 

 

 

4.  address (street, city, state, zip code)

 

 

 

 

 

 

 

 

 

 

5.  mo healthnet number

6.  prognosis

 

 

 

 

 

 

7.  diagnosis code

8.  diagnosis description

 

 

 

9.  name and address of facility where services are to be rendered if other than home or office

 

 

 

 

 

II. HCY (EPSDT) SERVICE REQUEST (MAY REQUIRE PLAN OF CARE)

partial

 

 

 

10.  date of hcy screen

 

11.  screening

full 

interperiodic 

 

12.  type of partial hcy screen

13.  screening provider name

 

 

 

 

 

 

14.  provider identifier

 

15.  telephone number

III. SERVICE INFORMATION

19.

 

20.

 

21.

 

 

 

22.

23.

 

 

16.

17.

 

18.

 

 

 

description of service/item

appr. denied

amount allowed if

ref.

procedure

 

modifiers

 

from

through

 

qty. or

amount to

no

code

 

 

 

 

 

 

 

units

be charged

 

priced by report

(1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(3)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(4)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(5)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(6)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(7)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(8)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(9)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(10)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(11)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(12)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24.  detailed explanation of medical necessity for services/equipment/procedure/prosthesis (attach additional pages if necessary)

 

IV. PROVIDER

 

 

 

 

 

 

 

 

V.  PRESCRIBING/PERFORMING PRACTITIONER

 

25.  provider name

 

 

 

 

 

 

 

 

29.  name

 

 

 

30.  telephone

26.  address

 

 

 

 

 

 

 

 

 

31.  address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

32.  date disability began

33.  period of medical need in months

 

 

 

 

 

 

 

 

 

 

 

fax number

 

 

 

 

 

 

 

 

 

34.  npi

 

 

 

taxonomy

 

 

 

 

 

 

 

 

 

i certify the information given in sections i and iii of this form is true, accurate, and

27.  npi

 

 

 

 

 

taxonomy

 

 

 

 

 

 

 

 

 

complete.

 

PRESCRIBING PHYSICIAN/PRACTITIONER

 

28.  signature

 

 

 

 

 

 

date

 

 

35.  signature of

date

VI. FOR STATE OFFICE USE ONLY

 

 

 

 

 

 

 

 

 

 

denial reason(s): refer to field 16 above by reference numbers (ref. no.)

 

 

 

 

 

 

IF APPROVED: services authorized to begin

mo 886-0858 (3-15)

date

reviewed by signature4

mo 8809

INSTRUCTIONS FOR COMPLETION

I. GENERAL INFORMATION - To be completed by the provider requesting the prior authorization. 1. leave blank

2. participant’s name - enter the participant’s name as it appears on the mo healthnet id card. enter the participant’s current address.

3. date of birth - enter the participant’s date of birth.

4. address - enter the participant’s address, city, state, and zip.

5. mo healthnet number - enter the participant’s 8-digit mo healthnet identification number as shown on the mo healthnet identification card or county letter of eligibility.

6. prognosis - enter the participant’s prognosis.

7. diagnosis code - enter the diagnosis code(s).

8. diagnosis description - enter the diagnosis description. if there is more than one diagnosis, enter all descriptions appropriate to the services being requested.

9. name and address of the facility where services are to be rendered if service is to be provided other than home or office.

II. HCY SERVICE REQUEST (Plan of care may be required, see your provider manual) 10. date of hcy screen - enter the date the hcy screen was done.

11. screening - check whether the screening performed was full, interperiodic, or partial.

12. type of partial hcy screen - enter the type of partial hcy screen that was performed. (e.g., vision, hearing, etc.)

13. screening provider name - enter the provider’s name who performed the screening.

14. provider identifier - enter the provider’s npi number who performed the screening.

15. telephone number - enter the screening provider’s telephone number including the area code.

III. SERVICE INFORMATION

16. ref. no. - (reference number) a unique designator (1-12) identifying each separate line on the request.

17. procedure code - enter the procedure code(s) for the services being requested.

18. modifier - enter the appropriate modifier(s) for the services being requested.

19. from - enter the from date that services will begin if authorization is approved (mm/dd/yy format).

20. through - enter the through date the services will terminate if authorization is approved (mm/dd/yy format).

21. description of service/item - enter a specific description of the service/item being requested.

22. quantity or units - enter the quantity or units of service/item being requested.

23. amount to be charged - enter the amount to be charged for the service.

24. detailed explanation of medical necessity of the service, equipment/procedure/prosthesis, etc. attach additional page(s) as necessary.

Do not use another Prior Authorization Form.

IV. PROVIDER REQUESTING PRIOR AUTHORIzATION

25. provider name - enter the requested provider’s information. if a clinic or group practice, also complete section v.

26. address - enter the complete mailing address in this field.

27. npi - enter the provider’s npi and taxonomy code (if applicable).

28. signature/date - the provider of services should sign the request and indicate the date the form was completed. (check your provider manual to determine if this field is required.)

V. PRESCRIBING/PERFORMING PRACTITIONER

this section must be completed for services which require a prescription such as durable medical equipment, physical therapy, or for services which will be prescribed by a physician/practitioner that require prior authorization, or when the provider in section iv is a clinic or group practice. check your provider manual for additional instructions.

29. name - enter the name of the prescribing/performing practitioner.

30. telephone number - enter the prescribing/performing practitioner telephone number including area code.

31. address - enter the address, city, state, and zip code.

32. date disability began - enter the date the disability began. for example, if a disability originated at birth, enter date of birth.

33. period of medical need in months - enter the estimated number of months the participant will need the equipment/services.

34. npi - enter the provider’s npi and taxonomy code (if applicable).

35. signature of prescribing/performing practitioner - the prescribing physician/practitioner must sign and indicate the date signed in mm/dd/yy format. (Signature stamps are not acceptable)

VI. FOR STATE OFFICE USE ONLY

approval or denial for each line will be indicated in the box to the right of section iii. also in this box the consultant will indicate allowed amount if procedure requires manual pricing.

at the bottom, the consultant may explain denials or make notations referencing the specific procedure code and description by number (1 thru 12). the consultant will sign or initial the form.

mo 886-0858 (3-15)

mo 8809

How to Edit Form Mo 886 0858 Online for Free

We were making the PDF editor with the prospect of making it as effortless to work with as it can be. This is why the procedure of creating the mo healthnet drug prior authorization form will be easy perform these particular actions:

Step 1: Press the "Get Form Now" button to begin.

Step 2: You're now on the file editing page. You may edit, add information, highlight specific words or phrases, place crosses or checks, and insert images.

Type in the details requested by the software to get the form.

mo healthnet prior authorization form blanks to consider

Write the demanded information in the III SERVICE INFORMATION ref, modifiers, code, from, through, description of serviceitem, qty or amount to units be charged, appr denied, amount allowed if priced by report, detailed explanation of medical, IV PROVIDER provider name, address, V PRESCRIBINGPERFORMING, telephone, and address area.

Entering details in mo healthnet prior authorization form step 2

It is essential to write some information in the field fax number, npi, signature, npi, taxonomy, i certify the information given in, signature of PRESCRIBING, date, taxonomy, date, VI FOR STATE OFFICE USE ONLY, IF APPROVED services authorized to, date, and reviewed by signature.

Filling in mo healthnet prior authorization form stage 3

Step 3: Hit "Done". It's now possible to export the PDF document.

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