Get Intermediate Care Facility For Individuals With Intellectual Disabilities (icf/id) And Nursing

Filling out the Intermediate Care Facility For Individuals With Intellectual Disabilities and Nursing Facilities Prior Authorization and Concurrent Review Request Form is a crucial process for obtaining necessary approvals for long-term care. This guide will provide step-by-step instructions to help you navigate the online submission of the form with ease.

Follow the steps to complete your request effectively.

1. Click the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Fill in the requesting provider information by entering your NPI number, tax ID, and provider name in the designated fields.
3. Provide the rendering provider information, including their NPI number and tax ID.
4. Enter patient details, specifically their Medicaid number, date of birth, name, address, city/state/ZIP code, and phone number.
5. Complete the patient guardian phone number, and the name and NPI of the Primary Medical Provider (PMP).
6. Fill in the preparer's information, such as the preparer's name and phone number.
7. Include ordering, prescribing, or referring (OPR) provider information, including their phone, fax, and NPI number.
8. Specify the service start date and the requested service code.
9. Indicate whether the member is currently on a waiver by selecting ‘Yes’ or ‘No’.
10. Input the requested duration for the service.
11. State whether the member has an assigned case manager with a ‘Yes’ or ‘No’ response.
12. Describe the member’s current location, such as home or hospital, and clarify if this is a permanent move or temporary placement.
13. Finally, review the information for accuracy, then sign and date the document to certify that the information is true and complete.
14. Once completed, save changes, then you can download, print, or share the form as necessary.

Complete your authorization request online today.