Get Pathways Pa Request Form - Pathways Radiology Pdf - Mainecare Maine

Filling out the Pathways PA Request Form for radiology services through Mainecare is a crucial step in ensuring timely medical procedures. This guide will walk you through the process, helping you to complete the form accurately and efficiently online.

Follow the steps to accurately fill out the Pathways Radiology PA request form online.

1. Click the ‘Get Form’ button to access the Pathways PA Request Form. This will allow you to open the document for editing.
2. Indicate the request type by placing an ‘X’ next to the appropriate option, selecting either ‘New PA Request’, ‘Update PA Request’, or ‘PA Supporting Documentation only’. If you select ‘Update PA Request’ or ‘PA Supporting Documentation only’, be sure to enter the Electronic PA number.
3. Enter the patient's name, Medicaid ID number (not Medicare), and their date of birth.
4. Fill in the requesting provider's information, including their name, 10-digit NPI number, and group NPI number.
5. Input the requesting provider's office address, including street address, city, state, and zip code.
6. Provide the servicing provider's name and their 10-digit NPI number.
7. State the primary diagnosis by entering the corresponding ICD code and description for the patient's condition.
8. For CT or PET procedures, document the CPT code and description, and indicate the dates of service (from and to). If uncertain about the exact date, a date range is acceptable.
9. Articulate the medical necessity for the requested procedure. Be specific about the patient's medical circumstances, including symptom duration and intensity.
10. Select ‘Yes’ or ‘No’ for the questions regarding MRI/MRA or ultrasound contra-indications and if the procedure is to evaluate cancer staging.
11. Provide any additional considerations by explaining unique circumstances that necessitate this imaging modality at this time.
12. Acknowledge that you have reviewed the ACR Appropriateness criteria by marking the checkbox.
13. Sign the form, confirming that your signature matches the requesting provider listed and enter the date of submission.
14. Once all sections are completed, users have the option to save changes, download, print, or share the form before submitting.

Begin completing your Pathways PA Request Form online now to ensure timely processing!