Mhcp Authorization Form PDF Details

The Minnesota Health Care Programs (MHCP) Authorization Form, identified by its form number DHS-4695-ENG, serves as a critical document in the administration of medical services, medical equipment, and supplies involving MHCP enrollees. This comprehensive form is designed to streamline the process of seeking authorization for a wide range of medical services and products by healthcare providers. It encompasses various sections including requestor information, authorization data, provider and recipient details, as well as service line information. Providers are prompted to fill in details ranging from the nature of the authorization request, pertinent dates for the start and end of the service, through to specific codes for procedures, diagnosis, and equipment. Additionally, the form mandates the inclusion of the provider’s information such as National Provider Identifier (NPI) or Universal Medical Provider Identification (UMPI), contact details, and information regarding the pay-to provider. This form not only demands precise information regarding the medical service or equipment requested but also underscores the need for supporting documentation to ensure a comprehensive review. Fulfillment of the form’s requirements facilitates the review process by Medical Review Agents and aids in the timely provision of essential healthcare services to recipients.

QuestionAnswer
Form NameMhcp Authorization Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesmhcp authorization, mhcp form, dhs 4695 eng, dhs4695 eng form

Form Preview Example

Minnesota Health Care Programs (MHCP)

Authorization Form

*DHS-4695-ENG*

DHS-4695-ENG

9-14

Page of

DOCUMENT CONTROL NUMBER (FOR INTERNAL USE ONLY)

Send to: Medical Review Agent

7900 International Plaza Drive, Suite 988 Bloomington, MN 55425

Fax: 1-866-889-6512

Requestor Information

For physician administered drugs (J-codes) send all supporting documentation by fax or mail to:

MHCP Prescription Drug Prior Authorization Review Agent c/o Health Information Designs, Inc.

391 Industry Drive

Auburn, AL 36832

Fax: 866-648-4574

REQUESTOR NAME

REQUESTOR PHONE NUMBER REQUESTOR AFFILIATION (check one) (for drug authorization only)

-

-

Pharmacy

Prescriber

 

 

Authorization Information

AUTHORIZATION TYPE

Medical Services Medical Equipment/Supplies

CHANGE TO EXISTING AUTHORIZATION

lChange for PA#

START DATE (MM/DD/YYYY)

END DATE (MM/DD/YYYY)

Pay-to Provider Information

PAY-TO PROVIDER NAME

ADDRESS

CITY

STATE

ZIP CODE

PHONE NUMBER

- -

FAX NUMBER

- -

NPI/UMPI

TAXONOMY CODE

Recipient Information

LAST NAME

FIRST NAME

MI

ID NUMBER

DATE OF BIRTH (MM/DD/YYYY)

Ordering/Referring Provider Information

NAME

NPI/UMPI

PHONE NUMBER

- -

FAX NUMBER

- -

Service Line Information

PROCEDURE CODE

MODIFIER (UP TO 4)

 

 

 

DIAGNOSIS CODE(S)

MODEL NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

START DATE (MM/DD/YYYY)

END DATE (MM/DD/YYYY)

RATE/CHARGE

QTY/UNITS

RENDERING PROVIDER NPI/UMPI

TOTAL AMOUNT

 

 

 

 

 

 

 

 

 

 

 

SERVICE DESCRIPTION/COMMENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

PROCEDURE CODE

MODIFIER (UP TO 4)

 

 

 

DIAGNOSIS CODE(S)

MODEL NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

START DATE (MM/DD/YYYY)

END DATE (MM/DD/YYYY)

RATE/CHARGE

QTY/UNITS

RENDERING PROVIDER NPI/UMPI

TOTAL AMOUNT

 

 

 

 

 

 

 

 

 

 

 

SERVICE DESCRIPTION/COMMENTS

Include supporting documentation

SIGNATURE

DATE

as necessary.

 

 

 

 

 

For more than two services or line items, submit additional Service Line Information on separate pages. Recipient Information

Page of

LAST NAME

FIRST NAME

MI

ID NUMBER

DATE OF BIRTH (MM/DD/YYYY)

Service Line Information

PROCEDURE CODE

MODIFIER (UP TO 4)

 

 

 

DIAGNOSIS CODE(S)

MODEL NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

START DATE (MM/DD/YYYY)

END DATE (MM/DD/YYYY)

RATE/CHARGE

QTY/UNITS

RENDERING PROVIDER NPI/UMPI

TOTAL AMOUNT

 

 

 

 

 

 

 

 

 

 

 

SERVICE DESCRIPTION/COMMENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

PROCEDURE CODE

MODIFIER (UP TO 4)

 

 

 

DIAGNOSIS CODE(S)

MODEL NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

START DATE (MM/DD/YYYY)

END DATE (MM/DD/YYYY)

RATE/CHARGE

QTY/UNITS

RENDERING PROVIDER NPI/UMPI

TOTAL AMOUNT

 

 

 

 

 

 

 

 

SERVICE DESCRIPTION/COMMENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

PROCEDURE CODE

MODIFIER (UP TO 4)

 

 

 

DIAGNOSIS CODE(S)

MODEL NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

START DATE (MM/DD/YYYY)

END DATE (MM/DD/YYYY)

RATE/CHARGE

QTY/UNITS

RENDERING PROVIDER NPI/UMPI

TOTAL AMOUNT

 

 

 

 

 

 

 

 

SERVICE DESCRIPTION/COMMENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

PROCEDURE CODE

MODIFIER (UP TO 4)

 

 

 

DIAGNOSIS CODE(S)

MODEL NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

START DATE (MM/DD/YYYY)

END DATE (MM/DD/YYYY)

RATE/CHARGE

QTY/UNITS

RENDERING PROVIDER NPI/UMPI

TOTAL AMOUNT

 

 

 

 

 

 

 

 

SERVICE DESCRIPTION/COMMENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

PROCEDURE CODE

MODIFIER (UP TO 4)

 

 

 

DIAGNOSIS CODE(S)

MODEL NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

START DATE (MM/DD/YYYY)

END DATE (MM/DD/YYYY)

RATE/CHARGE

QTY/UNITS

RENDERING PROVIDER NPI/UMPI

TOTAL AMOUNT

 

 

 

 

 

 

 

 

SERVICE DESCRIPTION/COMMENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

PROCEDURE CODE

MODIFIER (UP TO 4)

 

 

 

DIAGNOSIS CODE(S)

MODEL NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

START DATE (MM/DD/YYYY)

END DATE (MM/DD/YYYY)

RATE/CHARGE

QTY/UNITS

RENDERING PROVIDER NPI/UMPI

TOTAL AMOUNT

 

 

 

 

 

 

 

 

SERVICE DESCRIPTION/COMMENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

PROCEDURE CODE

MODIFIER (UP TO 4)

 

 

 

DIAGNOSIS CODE(S)

MODEL NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

START DATE (MM/DD/YYYY)

END DATE (MM/DD/YYYY)

RATE/CHARGE

QTY/UNITS

RENDERING PROVIDER NPI/UMPI

TOTAL AMOUNT

 

 

 

 

 

 

 

 

SERVICE DESCRIPTION/COMMENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DHS-4695-ENG 9-14

MHCP Authorization Form Instructions

Complete one form per recipient.

Requestor Information

Requestor Name: Enter the first and last name of the person requesting this authorization.

Requestor Phone Number: Enter the requestor’s phone number.

Requestor Affiliation: For physician administered drug authorizations, select whether the requestor is affiliated with a pharmacy or prescriber.

Ordering/Referring Provider Information

Name: Enter the name of the provider who ordered, referred or prescribed the service.

NPI/UMPI: Enter the provider’s 10-digit NPI or UMPI.

Phone Number: Enter the provider’s phone number.

Fax Number: Enter the provider’s fax number.

Authorization Information

Authorization type: Place an “X” in the appropriate Authorization Type box.

Change to existing Authorization: If you are making a change to an existing authorization, mark the Change for PA

#box and print the 11-digit authorization number you wish to update.

Start date: Enter the first date of service (MM/DD/YYYY) for this authorization request. If approved, this will be the effective date of the authorization. If service has already been provided, enter the date the service began.

End date: Enter the last date of service (MM/DD/YYYY) for the authorization request. If service has already been provided and will not continue, enter the last date the service was provided.

Pay-to Provider Information

Pay-to Provider Name: Enter the name of the pay-to provider for the service.

Address: Enter the provider’s street address, city, state and zip code. For consolidated providers, enter the address for the location where the service was performed.

Phone Number: Enter the provider’s phone number.

Fax Number: Enter the provider’s fax number.

NPI/UMPI: Enter the provider’s NPI/UMPI.

Taxonomy Code: For consolidated providers, enter the provider’s taxonomy code, when applicable.

Service Line Information

Procedure code: Enter the appropriate CPT/HCPCS code for the procedure/service you are requesting for authorization.

Modifier: Enter any appropriate CPT/HCPCS modifier(s) for the procedure/service you are requesting for authorization.

Diagnosis code(s): Enter the recipient’s ICD diagnosis code(s) relevant to the procedure/service for which you are requesting authorization.

Model number: If you are requesting authorization for a medical supply, enter the model number or UPC. If the medical supply does not have a model number or UPC, leave blank.

Start date: Enter the first date of service (MM/DD/YYYY) for the procedure listed.

End date: Enter the last date of service (MM/DD/YYYY) for the procedure listed.

Rate: Enter your usual and customary charge or requested rate of payment per unit.

QTY/Units: Enter the total number of procedure/service units.

Rendering provider NPI/UMPI: Enter the 10-digit NPI or UMPI of the rendering provider if different than the NPI/ UMPI listed under Provider Information above.

Total amount: Enter the total reimbursement amount (rate multiplied by qty/units) you are requesting for this service.

Service description/comments: Enter comments and/or description of the service to be provided.

Sign and date the form.

Recipient Information

Last name: Enter the recipient’s last name.

First name: Enter the recipient’s first name.

MI: Enter the recipient’s middle initial (if known).

ID Number: Enter the recipient’s 8-digit MHCP ID number.

Birthdate: Enter the recipient’s birth date in MM/DD/YYYY format.

View general Claims Submission guidelines and refer to MHCP authorization policies.

DHS-4695-ENG 9-14

How to Edit Mhcp Authorization Form Online for Free

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Step number 1 of filling in mhcp authorization form

2. Immediately after this selection of blanks is completed, go to enter the suitable details in these: ADDRESS, CITY, STATE, ZIP CODE, PHONE NUMBER, FAX NUMBER, NPIUMPI, TAXONOMY CODE, Recipient Information LAST NAME, FIRST NAME, ID NUMBER, DATE OF BIRTH MMDDYYYY, OrderingReferring Provider, NPIUMPI, and PHONE NUMBER.

Stage no. 2 of filling in mhcp authorization form

3. The following segment focuses on PROCEDURE CODE, MODIFIER UP TO, DIAGNOSIS CODES, MODEL NUMBER, START DATE MMDDYYYY, END DATE MMDDYYYY, RATECHARGE, QTYUNITS, RENDERING PROVIDER NPIUMPI, TOTAL AMOUNT, SERVICE DESCRIPTIONCOMMENTS, Include supporting documentation, SIGNATURE, and DATE - fill in every one of these blank fields.

Step # 3 in filling in mhcp authorization form

4. To go forward, the following part will require filling out a few blanks. These comprise of For more than two services or line, Page, Recipient Information LAST NAME, Service Line Information PROCEDURE, MODIFIER UP TO, FIRST NAME, ID NUMBER, DATE OF BIRTH MMDDYYYY, DIAGNOSIS CODES, MODEL NUMBER, START DATE MMDDYYYY, END DATE MMDDYYYY, RATECHARGE, QTYUNITS, and RENDERING PROVIDER NPIUMPI, which you'll find vital to going forward with this particular PDF.

Completing segment 4 in mhcp authorization form

5. Now, the following last section is what you will have to wrap up prior to closing the PDF. The fields in this instance include the next: START DATE MMDDYYYY, END DATE MMDDYYYY, RATECHARGE, QTYUNITS, RENDERING PROVIDER NPIUMPI, TOTAL AMOUNT, SERVICE DESCRIPTIONCOMMENTS, PROCEDURE CODE, MODIFIER UP TO, DIAGNOSIS CODES, MODEL NUMBER, START DATE MMDDYYYY, END DATE MMDDYYYY, RATECHARGE, and QTYUNITS.

How to fill in mhcp authorization form step 5

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