Magnolia Health Plan Form PDF Details

Do you have medical coverage through Magnolia Health Plan and need to fill out a form? The process is easier than you think! Whether you have already established your health plan with Magnolia or are considering signing up for one, understanding the basics of completing forms is essential. In this blog post, we'll walk you through what's involved in filling out the standard Magnolia Health Plan form so that you can ensure accuracy and make sure all necessary steps are taken when submitting it. Read on to learn more!

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

You may prepare magnolia prior authorization easily with the help of our online tool for PDF editing. To retain our tool on the forefront of convenience, we strive to implement user-driven features and enhancements on a regular basis. We're at all times looking for feedback - join us in revolutionizing how you work with PDF files. If you're looking to begin, here is what it will take:

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.

Step 3: Confirm that the details are accurate and then click "Done" to progress further. Acquire your magnolia prior authorization once you sign up at FormsPal for a free trial. Readily gain access to the document inside your FormsPal cabinet, together with any modifications and changes being automatically kept! When using FormsPal, you can easily fill out documents without stressing about database breaches or records getting distributed. Our protected software helps to ensure that your private data is stored safely.

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