Get Kentucky Medicaid Mco Map 9 Mco 012016

This guide provides a clear, step-by-step process for filling out the Kentucky Medicaid Mco Map 9 Mco 012016 form online. Proper completion of this form is essential for ensuring timely processing of prior authorization requests.

Follow the steps to successfully complete the form online:

1. Press the ‘Get Form’ button to access the Kentucky Medicaid Mco Map 9 Mco 012016 form and open it in the editor.
2. Select the appropriate MCO by checking the corresponding box for the member's enrolled plan, including options such as Anthem BCBS Medicaid or Humana – CareSource.
3. Fill in the date and time when the request is being submitted, along with the requesting provider’s name, telephone number, fax number, and NPI number.
4. Indicate the type of request by selecting one of the options: Urgent, Non-Urgent, Pre-Service, Post-Service, Concurrent, or Emergent.
5. Complete the member information section with the member's name, Medicaid ID number, MCO ID number, date of birth, and pregnancy status.
6. Provide the member’s primary care provider information, including name, phone number, and NPI.
7. Indicate whether the member's situation involves a work-related injury or a motor vehicle accident.
8. Specify if the member has other insurance coverage, and if so, provide the insurer's name and Medicare details, if applicable.
9. Fill out the servicing provider information, including their name, NPI, tax ID, address, city, state, ZIP code, phone number, and fax number.
10. State whether any supporting documents are included and indicate the number of documents being submitted.
11. Select the type of service being requested from the provided options, ensuring to specify if it is related to behavioral health, medical care, or any other category.
12. Ensure that the request includes the primary ICD-10 code, a description, the dates of service, procedure/diagnosis, service codes, requested service, and number of visits.
13. Complete the form by entering your name and phone number in the section provided for the person completing the form.
14. Once all fields are filled out, save your changes, download the completed form, print it for your records, or share it as necessary.

Prepare to complete your documents online today for efficient handling of your requests.