Get Medicaid Therapy

This guide provides a clear and comprehensive overview of how to complete the Medicaid Therapy prior authorization request form. Users will find step-by-step instructions tailored to their needs, ensuring a smooth submission process online.

Follow the steps to successfully complete your Medicaid Therapy request form

1. Click ‘Get Form’ button to obtain the form and open it in the editor. This will allow you to access the necessary fields you need to fill out.
2. Enter the therapy provider information. Provide the facility or provider name, street address, city, state, telephone number, ZIP code, and fax number. This contact information is essential for any communication regarding your request.
3. Fill in the provider tax ID number, billing national provider identifier (NPI), individual NPI number, facility NPI number, and individual tax ID number. Ensure that all identifiers are accurate to avoid any delays.
4. Complete the patient information section. Input the patient's first name, last name, date of birth, and the alpha prefix health plan member ID number. This ensures the correct patient is associated with the authorization request.
5. In the request information section, indicate whether this request is for post-operative therapy visits. Specify the request type, whether it is for the onset of therapy services or an extension of them, and fill in the initial evaluation date.
6. Select the type of therapy services being requested, such as physical therapy, occupational therapy, or speech therapy. Include the diagnosis code in ICD-10 format to clearly identify the medical necessity.
7. Finally, review all the filled information for accuracy. Once confirmed, you can save your changes, download the completed form, and be ready to fax it to OrthoNet at 1-855-596-7626 along with any required supporting documentation.

Complete your Medicaid Therapy authorization request online for a seamless submission process.