Get Oh Caresource Medicaid Provider Prior Authorization Request Form 2021-2025

Completing the OH CareSource Medicaid Provider Prior Authorization Request Form is an essential process for obtaining necessary approvals for medical services. This guide will provide you with clear, step-by-step instructions to help you fill out the form accurately and efficiently online.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the OH CareSource Medicaid Provider Prior Authorization Request Form online.
2. Begin by filling out the patient information section. Include the member's last name, first name, member ID number, date of birth, and phone number. Complete the member's address details, including city, state, and ZIP code.
3. Indicate whether the request is routine or urgent by selecting the correct option. Provide the date of request.
4. Attach clinical notes that detail the patient’s history and prior treatment. This is essential for proper evaluation.
5. Specify the type of service being provided: inpatient, outpatient, or other. Also, indicate the place of service, such as office or home.
6. Fill out the information for the ordering provider, including name, tax ID, NPI, address, phone number, city, state, and ZIP code.
7. Provide the start and end dates for the service in the specified format (mm/dd/yyyy).
8. Complete the details for the facility or servicing provider, including name, tax ID, NPI, address, city, state, and ZIP code.
9. Input the diagnosis codes (DX Code 1, 2, and 3) as applicable.
10. Enter additional service details, including CPT/HCPCS codes, description of service, and the number of visits required.
11. Indicate whether there is an updated authorization number and provide information about any other insurance if applicable.
12. Fill in the contact name and phone number for follow-up, along with the contact fax number.
13. Once all information is filled in correctly, review the form for accuracy. Save changes, then choose to download, print, or share the completed form as necessary.

Complete your documents online today for a smooth prior authorization process.