Get Utilization Threshold Program 2015-2025

The Utilization Threshold Program is designed to manage the number of medically necessary services that Medicaid members can receive within a benefit year. This guide offers clear, step-by-step instructions on how to complete the program's application form online, ensuring users can navigate the process with ease.

Follow the steps to complete the application form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out Section 1 – Member Information. Enter the member ID number, starting month of the benefit year, and the member's name. Additionally, provide their street address, city, state, ZIP code, sex, and birth date in MM/DD/YYYY format.
3. Next, proceed to Section 2 – Provider Information. Here, you will enter the provider's National Provider Identifier (NPI) if enrolled in Medicaid, or a license number if not. Include the profession code, provider's name, full correspondence address, and phone number.
4. In Section 3 – Medical Data, indicate if the member received an At Limits letter by marking Yes or No. Enter the relevant diagnosis codes describing the member's condition. Also, specify the amount of increase in services being requested and the duration of the need.
5. Ensure that the form is signed by the requesting provider, including both the date of signature and print the name beneath the signature. Remember, rubber stamps or photocopies are not acceptable.
6. Finally, review all the information for accuracy. Once confirmed, you can save changes, download, print, or share the completed form as required.

Start completing your documents online today for a smoother process.