Get Mo Mo 886-0858 2015-2026

The MO MO 886-0858 is a prior authorization request form used by the Missouri Department of Social Services. This guide provides clear, step-by-step instructions on how to fill out the form online to ensure accurate and efficient submission.

Follow the steps to successfully complete the MO MO 886-0858 online.

1. Click the ‘Get Form’ button to access the MO MO 886-0858 form and open it in your preferred online editor.
2. In Section I, General Information, complete the following fields: 1. Leave blank. 2. Enter the participant’s name as listed on their MO HealthNet ID card. 3. Provide the date of birth of the participant. 4. Fill in the address, including street, city, state, and zip code. 5. Input the 8-digit MO HealthNet identification number. 6. Enter the prognosis for the participant. 7. Provide the diagnosis code(s) along with the diagnosis description. Include all relevant descriptions. 8. If services are to be provided at a facility other than at home or office, provide the facility’s name and address.
3. For Section II, HCY Service Request, complete the following fields: 10. Enter the date of the HCY screen. 11. Indicate whether the screening performed was full, interperiodic, or partial. 12. If applicable, specify the type of partial HCY screen conducted (e.g., vision, hearing). 13. Provide the name of the screening provider.
4. In Section III, Service Information, fill out the following: 16. Reference number to identify each line on the request. 17. Enter relevant procedure codes for requested services. 18. Input any necessary modifiers for these services. 19. State the from date for service initiation, if approved. 20. Specify the through date for the service termination, if approved. 21. Describe the service or item being requested clearly. 22. Enter the quantity or units being requested. 23. Provide the amount to be charged for these services. 24. Include a detailed explanation of the medical necessity, attaching additional pages if needed.
5. In Section IV, Provider Information, complete: 25. Enter the provider’s name. 26. Provide the complete mailing address. 27. Include the provider’s NPI number and taxonomy code if applicable. 28. The provider should sign and date the form verifying the request.
6. In Section V, Prescribing/Performing Practitioner, fill out the following: 29. Name of the prescribing/performing practitioner. 30. Telephone number of the practitioner. 31. Address of the practitioner. 32. Enter the date the disability began. 33. Specify the period of medical need in months. 34. Include the practitioner’s NPI and taxonomy code if applicable. 35. The practitioner must sign and date this section.
7. Upon completing all sections, review your entries for accuracy. You can now save your changes, download the form, print it for your records, or share it as necessary.

Complete the MO MO 886-0858 form online today to facilitate your prior authorization request.