Get Skilled Therapy Services (ot/pt/st) Prior Authorization Form

This guide provides a clear and structured approach to completing the Skilled Therapy Services (OT/PT/ST) Prior Authorization Form online. Following these steps will ensure accurate submission and improve the chances of timely approval for necessary therapy services.

Follow the steps to complete the authorization form online effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by identifying the request type at the top of the form. Select either ‘Initial Request’ or ‘Continuation of Services’ based on the situation. Note that this form is not to be used for urgent requests.
3. In the Member Information section, fill in the WellCare ID number, Medicare/Medicaid number, last name, first name, middle initial, phone number, and date of birth. Indicate whether there is third-party insurance by selecting ‘Yes’ or ‘No’. If ‘Yes’, attach a copy of the insurance card or provide the insurer’s name, policy type, and number.
4. Provide the Ordering Physician Information, including their WellCare ID number, NPI number, last name, first name, street address, city, state, zip code, phone number, fax number, provider type/specialty, and name of the requester.
5. Complete the Treating Provider Information in the same manner as the ordering physician, ensuring all details are accurate and up-to-date.
6. Fill out the Facility Information section by selecting the place of service such as Office, CORF, Home, Hospice, Outpatient Hospital, or Other. Enter the facility's WellCare ID, NPI number, name, hospital contact, and full address.
7. In the Requested Services section, include the requested dates of service, number of visits attended to date, original start of care date, and previous authorization number if applicable. Specify how the treatment will be rendered and the corresponding frequency or total visit count.
8. List the necessary ICD-9 and CPT/HCPCS codes along with their descriptions for the planned services and conditions. You may need to include multiple codes as required.
9. Attach any supporting documentation that demonstrates medical necessity such as history and physical reports, progress notes, lab results, and treatment plans.
10. Review all the information for accuracy and completeness, ensuring all required fields are filled. Finally, save your changes, then download, print, or share the form as needed.

Complete your Skilled Therapy Services Prior Authorization Form online to ensure timely therapy approvals.