Initial Authorization Request Form - Maine

Outpatient Procedures Surgical Procedures performed in outpatient setting In -State Inpatient Procedures ... Enter at least one primary diagnosis for the PA. This must be a corresponding ICD-10 Diagnosis code. ... Group Provider Name and NPI/API– Enter the name and NPI/API if the referral is to a Group of Providers. 10. Facility, Agency ...

  Primary, Procedures, Provider, Performed, Procedures performed