Get Wv Medicaid Out-of-network Prior Authorization Forms - Aps Healthcare

Filling out the Wv Medicaid Out-of-network Prior Authorization Forms is an essential process for obtaining services not available in-network. This guide will provide you with clear, step-by-step instructions to ensure that you can complete the form accurately and efficiently.

Follow the steps to fill out the form correctly.

1. Click the ‘Get Form’ button to access and open the form in your preferred editor.
2. Provide the Referring/Ordering Provider's information, including the name, NPI, West Virginia Medicaid ID, address, and contact details. Ensure that the provider is actively enrolled with West Virginia Medicaid.
3. Fill in the Out-of-Network Servicing Provider/Practitioner section by providing their name, NPI, address, and contact information. The servicing provider must confirm their willingness to enroll with West Virginia Medicaid.
4. Complete the Out-of-Network Facility/Location information, ensuring it matches the details of the institution providing the services. Confirm that the facility agrees to enroll with Medicaid.
5. Enter the Member's Medicaid Number, Social Security Number, first and last names, date of birth, and address, including city, state, and ZIP code. If the member is a minor, include the name of the parent or guardian.
6. Provide medical justification for the out-of-network request. Briefly describe the requested service(s) and explain why it cannot be obtained from an enrolled in-network provider.
7. Select the type of request from the options provided (e.g., inpatient admission, outpatient surgery). Supply the request date and the expected service start date.
8. Detail the diagnosis and service codes requested, including ICD-9 descriptions and corresponding CPT service codes for each condition.
9. Indicate whether physician orders are included, and if not, provide a reason. Also, indicate if there are any relevant diagnostic studies and if they are attached.
10. Review all provided information for completeness and accuracy. Once satisfied, save changes, and proceed to download, print, or share the form as needed.

Complete your Wv Medicaid Out-of-network Prior Authorization Form online today to ensure timely access to necessary services.