Get Outpatient Authorization Request (medicaid) - Wellcare

Completing the Outpatient Authorization Request form for Medicaid through WellCare is crucial for ensuring that members receive the necessary care. This guide provides a step-by-step approach to effectively fill out and submit the form online.

Follow the steps to complete your outpatient authorization request online.

1. Click ‘Get Form’ button to access the form, enabling you to fill it out conveniently in an online format.
2. In the member section, enter the member's plan ID, last name, first name, phone number, and date of birth. Ensure that all information is accurate to prevent any delays.
3. In the requesting provider section, fill in the provider ID, first and last name, phone number, specialty, and fax number. This helps to identify who is making the request.
4. For the treating provider section, if you want the plan to assign a treating provider, check the designated box. Otherwise, input the provider's ID, first and last name, address, city, state, ZIP, phone number, and fax number.
5. In the facility section, select the type of facility. If you want the plan to assign a facility, check the designated box. Otherwise, provide the facility ID, name, address, city, state, ZIP, phone number, and fax number.
6. Under service requested, fill in the planned date of service, primary ICD-9 code, CPT-4/HCPC code, and any additional procedure codes necessary. Provide a clear description of the procedure or services required.
7. In the pertinent clinical summary section, include any additional notes or attach supporting clinical records relevant to the request.
8. Review the completed form for accuracy and completeness. Once satisfied, save changes, and follow the instructions for downloading, printing, or sharing the completed request.

Complete your outpatient authorization request online for timely processing and care.