Georgia - Outpatient Medicaid Prior Authorization Fax Form

1 *0678* Outpatient MEDICAIDPRIOR Authorization FAX FORMC omplete and Fax to:1-866-532-8834 Request for additional units. Existing Authorization UnitsStandard Request Urgent Request - I certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within 48 hours to avoid complications and unnecessary suffering or severe REQUESTS MUST BE SIGNED BY THE REQUESTING PHYSICIAN TO RECEIVE PRIORITY. *INDICATES REQUIRED FIELDMEMBER INFORMATIONDate of Birth*Member ID/ Medicaid ID *Last Name, FirstREQUESTING PROVIDER INFORMATIONR equesting NPI*Requesting TIN*Requesting Provider Contact NameRequesting Provider NamePhoneFaxSERVICING PROVIDER / FACILITY INFORMATIONSame as Requesting Provider Servicing NPI**Servicing TINS ervicing Provider Contact NameServicing Provider/Facility NamePhoneFax(MMDDYYYY)XAUTHORIZATION REQUESTP rimary Procedure Code*Additional Procedure CodeStart DateOR Admission Date*Diagnosis Code*(MMDDYYYY)(CPT/HCPCS)(Modifier)(Mod ifier)Additional Procedure CodeAdditional Procedure CodeEnd Date ORDischarge Date Total Units/Visits/Days(CPT/HCPCS)(Modifier)(I CD-10)(MMDDYYYY) (CPT/HCPCS)(CPT/HCPCS)(Modifier)

2 Outpatient SERVICE TYPE*(Enter the Service type number in the boxes)401 Cardiac Pulmonary RehabDME 417 Rental120 Purchase299 Drug Testing709 Genetic Testing249 Home Health600 Home Infusion410 ObservationOccupational Therapy244 Outpatient Hospital245 Other Site497 Office Visit/Specialty Consult927 Outpatient Hospice794 Outpatient Services(Purchase Price)$Physical Therapy144 Outpatient Hospital145 Other SiteSpeech Therapy744 Outpatient Hospital745 Other Site724 TransportationFor High Tech Imaging, please continue to contact NIAALL 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 : An Authorization is not a guarantee of payment.

3 Member must be eligible at the time services are rendered. Services must be a covered Health Plan Benefit and medically necessary with Prior Authorization as per Plan policy and : The information contained in this transmission is confidential 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 03 19 2015GA-PAF-0678