Magnolia Health Plan Form PDF Details

Healthcare providers and facilities navigating the complexities of insurance coverage understand the importance of prior authorization. The Magnolia Health Plan form, crucial for ensuring that outpatient services are approved and covered, stands as a key document in this process. By submitting the MS-PAF-0346 Outpatient Prior Authorization Fax Form to the specified fax number, healthcare providers can request authorization for various outpatient services. This includes standard and urgent requests, with the latter requiring a signature from the requesting physician to highlight its urgency. The form gathers essential details, including member information like Medicaid ID and Date of Birth, along with the requesting provider's data, servicing provider/facility information, and specifics about the authorization request such as procedure codes, diagnosis codes, and service types. It emphasizes the need to include supporting clinical information to avoid delays and clearly states that an authorization does not guarantee payment, underlining the importance of eligibility and adherence to plan policies. Moreover, the form respects confidentiality in line with the Health Insurance Portability and Accountability Act of 1996, ensuring that the information shared is protected and used solely for its intended purpose. By accurately completing and submitting this form, healthcare providers can facilitate a smoother process for securing the necessary prior authorizations, thus streamlining patient access to required outpatient services.

QuestionAnswer
Form NameMagnolia Health Plan Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmagolia health pa forms, magnolia plan prior authorization form, magnolia prior authorization, magnolia prior authorization form

Form Preview Example

MS-PAF-0346

OUTPATIENT

Prior Authorization Fax Form

Fax to: 1-877-650-6943

Request for additional units. Existing Authorization

Units

 

Standard Request - Determination within 2 business days

Urgent Request - I certify this request is urgent and medically necessary to treat an injury,

of receiving all necessary information

illness or condition (not life threatening) within 48 hours to avoid complications and

 

 

 

 

unnecessary sufering or severe pain.

X

URGENT REqUESTS MUST BE SIGNED BY THE REqUESTING PHYSICIAN TO RECEIvE PRIORITY.

*INDICATES REQUIRED FIELD

 

 

Date of Birth *

 

 

 

MEMBER INFORMATION

 

 

 

Member ID/Medicaid ID *

 

Last Name, First

(MMDDYYYY)

 

 

REQUESTING PROVIDER INFORMATION

 

 

Requesting NPI *

Requesting TIN *

 

Requesting Provider Contact Name

Requesting Provider Name

 

Phone

Fax

SERVICING PROVIDER / FACILITY INFORMATION

Same as Requesting Provider

Servicing NPI *

Servicing TIN*

 

Servicing Provider Contact Name

*0346*

Servicing Provider/Facility Name

Phone

Fax

 

AUTHORIZATION REQUEST

Primary Procedure Code *

Additional Procedure Code

Start Date OR Admission Date

*

Diagnosis Code

*

(CPT/HCPCS)

(Modiier)

(CPT/HCPCS)

(Modiier)

(MMDDYYYY)

 

(ICD-9)

 

Additional Procedure Code

Additional Procedure Code

End Date OR Discharge Date

 

Total Units/visits/Days

(CPT/HCPCS)

(Modiier)

(CPT/HCPCS)

(Modiier)

(MMDDYYYY)

 

 

 

For school-aged Members (Age 3-21) with disabilities/special needs as deined in the Individual with Disabilities Education Act (IDEA):

Is/will the Member be receiving Therapy Services at school? Yes

No

 

 

 

Has Individualized Education Program (IEP) been completed? Yes

No

(If yes, please attach)

 

 

OUTPATIENT SERVICE TYPE* (Fill in the square with an X)

 

Oice Visit / Consult (Non Par Only)

Sleep Study

Prosthetics

 

 

 

 

Auditory Services

Home Health

 

Office Visit

 

 

 

Hospice

 

 

Sterotactic Radiosurgery

Biopharmacy

 

Other Site

 

 

Inpatient

 

Therapy

 

 

 

 

 

Cardiac Nuclear Scans

Outpatient

 

Orthotics

Physical Therapy

 

 

 

 

 

 

 

 

Dialysis

Neuropsychological Testing

Outpatient Services

Occupational Therapy

 

 

DME

Nutritional Services

 

Outpatient Surgery

Speech Therapy

 

Genetic Testing

Observation

 

Pain Management

Transportation (nonemergent)

ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED. COPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED.

LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION.

Disclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Beneit and medically necessary with prior authorization as per Plan policy and procedures.

Conidentiality: The information contained in this transmission is conidential and may be protected under the Health Insurance Portability and Accountability Act of 1996.

If you are not the intended recipient any use, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and destroy this document.

How to Edit Magnolia Health Plan Form Online for Free

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Step 1: Click the orange "Get Form" button above. It will open our pdf editor so you could start filling out your form.

Step 2: With our state-of-the-art PDF editing tool, you are able to do more than simply fill out blank fields. Edit away and make your documents appear faultless with customized textual content incorporated, or modify the file's original input to perfection - all supported by the capability to add any pictures and sign it off.

It's an easy task to fill out the form adhering to our detailed guide! This is what you should do:

1. It is very important complete the magnolia prior authorization accurately, so take care when filling in the sections that contain all these blank fields:

magnolia prior fax conclusion process detailed (stage 1)

2. Once the prior part is done, proceed to type in the relevant details in all these: Servicing ProviderFacility Name, Phone, Fax, AUTHORIZATION REQUEST Primary, Additional Procedure Code, Start Date OR Admission Date, Diagnosis Code, CPTHCPCS, Modiier, CPTHCPCS, Modiier, MMDDYYYY, ICD, Additional Procedure Code, and Additional Procedure Code.

Step no. 2 of submitting magnolia prior fax

3. The following section should also be fairly easy, Neuropsychological Testing, Outpatient Services, Dialysis, DME, Occupational Therapy, Nutritional Services, Outpatient Surgery, Speech Therapy, Genetic Testing, Observation, Pain Management, Transportation nonemergent, ALL REQUIRED FIELDS MUST BE FILLED, LACK OF CLINICAL INFORMATION MAY, and Disclaimer An authorization is not - these fields needs to be filled out here.

Completing segment 3 of magnolia prior fax

Always be really attentive when completing Dialysis and Neuropsychological Testing, since this is where most people make a few mistakes.

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