Get Kansas Acute And Ltc/ltss Prior Authorization Fax Request Form

Filling out the Kansas Acute and LTC/LTSS Prior Authorization Fax Request Form is essential for requesting necessary healthcare services. This guide provides clear and concise instructions to help you complete the form efficiently, ensuring that all required information is submitted accurately.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date in the designated field. This is important for tracking the request.
3. Provide the contact person’s name and phone number, ensuring accurate communication.
4. Fill in the requesting provider information, including TIN/NPI and fax number for processing.
5. Indicate if the fax line used is HIPAA secure by selecting 'Yes' or 'No'.
6. Fill out the member information: enter the member's name, ID, date of birth, and phone number.
7. Indicate if the member is pregnant or if the request relates to a motor vehicle or work-related injury.
8. If the member has other insurance, provide the insurance name and policy number.
9. Select the type of request from options like inpatient or outpatient, and choose the urgency level: routine or expedited/urgent.
10. Enter servicing provider and facility information, including names, addresses, and contact details.
11. Complete the clinical information section with diagnoses, ICD-9 codes, required CPT/HCPCS codes, and treatment details.
12. Finally, review all entries for accuracy, then save changes, download a copy, print, or share the completed form as needed.

Complete your form online today to ensure timely and effective healthcare service requests.