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  • Passport Health Plan Dme Prior Authorization Form

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PASSPORT HEALTH PLAN (PHP) DME Prior Authorization Form Patient Information Patient Name: PHP ID or SSN: Date of Birth: Primary ICD 9 diagnosis Secondary ICD9 diagnosis Passport Health Plan Ordering.

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1-800-MEDICARE (1-800-633-4227) For specific billing questions and questions about your claims, medical records, or expenses, log into your secure Medicare account, or call us at 1-800-MEDICARE.

To change your managed care organization, call toll free (855) 446-1245 or (800) 635-2570 from 8 a.m. to 6 p.m. Eastern time to speak with a Medicaid services representative or go online to the kynect website. All plan changes made during open enrollment will take effect on Jan. 1, 2023.

​​​​​​​​​​​​​​​​​​​​​​Medicaid provides medical assistance to eligible low-income Kentuckians. Use the links below to learn more about some available programs and services. If members have any questions, please contact Member Services toll-free at (800) 635-2570.

By faxing your request to 800-540-2406.

You must also be a resident of Kentucky and a U.S. citizen, lawful permanent resident or have legal status. Call Passport today to see if you qualify.

If you need these services, call Member Services at (800) 578-0603. TTY (for hearing impaired) is 711. You can also email your complaint to civil.rights@molinahealthcare.com. Or, fax your complaint to (502) 585-8461.

These are the main income rules for income-based Medicaid: If your family's income is at or under 138% of the Federal Poverty Guidelines (FPG) ($20,120 per year for an individual; $41,400 for a family of four), you may qualify.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232