Get Centennial Care Prior Authorization Request Form Centennial Care Prior Authorization Request Form

The Centennial Care Prior Authorization Request Form is an essential document required for obtaining prior authorization from Medicaid managed care. Completing this form accurately ensures that users receive the necessary approvals for medical services in a timely manner.

Follow the steps to fill out the Centennial Care Prior Authorization Request Form.

1. Press the ‘Get Form’ button to retrieve the Centennial Care Prior Authorization Request Form and open it for completion.
2. Fill in the request date at the top of the form. This date should reflect when the request is being submitted.
3. Indicate the appropriate Medicaid Managed Care organization by selecting from the options, such as BCBS, Molina, or Presbyterian.
4. Provide member information in the designated fields. This includes the member's name, ID number, date of birth, information about any other insurance carriers, their policy number, and contact phone number.
5. Complete the provider information section. Include the requesting provider's name, phone number, and fax number, as well as the servicing provider or facility's details.
6. Select the type of request by checking either 'New/Initial Request' or 'Ongoing Care' and fill in any previous authorization numbers if applicable.
7. Indicate the type of service requested by checking the relevant options, such as DME/Prosthetic/Orthotic or Outpatient Surgery.
8. In the 'Diagnosis(es)' section, enter the required ICD-9 codes for the patient's condition.
9. In the 'Procedure(s)' section, provide the necessary CPT or HCPC codes associated with the requested services.
10. Fill out the requested effective date, end date, and number of visits or units needed.
11. Attach all relevant clinical information that supports the authorization request, ensuring that all documentation is comprehensive and includes any prior treatments.
12. Review the completed form for accuracy. Once satisfied, save the changes, and opt to download, print, or share the form as required.

Complete your Centennial Care Prior Authorization Request Form online today to ensure timely processing of your request.