Get Oh Caresource Medicaid Provider Prior Authorization Request Form 2015

The OH CareSource Medicaid Provider Prior Authorization Request Form is essential for obtaining necessary approvals for medical services. This guide provides a clear, step-by-step approach to filling out the form online, ensuring that users can efficiently navigate the process.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by filling out the patient information section. Include the request date, member ID, last name, first name, address, date of birth, and phone number. Make sure all fields are accurately completed.
3. Choose the urgency level of the request by marking either 'Routine' or 'Urgent (72 hours)'. This indicates how quickly the authorization is needed.
4. Attach clinical notes regarding the patient's history and prior treatments. Ensure these are concise and relevant.
5. In the ordering provider section, enter the provider’s name, tax ID, NPI, phone number, and fax number. Complete the provider's address for contact purposes.
6. Specify the date(s) of service requested and fill in the facility or service provider's first and last name, along with their address and contact information.
7. List the diagnostic codes (DX Codes) and provide a brief description of the relevant diagnosis.
8. Detail the requested procedures, services, or surgeries by clearly identifying them, along with the procedure codes (CPT/HCPCS) and their quantities.
9. If applicable, indicate any durable medical equipment or orthotics needed, alongside the make, model, and usual & customary charge.
10. Specify the number of visits required and circle the appropriate number, or indicate 'Other' if necessary. If extending a previous authorization, provide the authorization number and requested extension date.
11. Complete the other liability section if there are additional insurance details, such as work or auto insurance.
12. Finally, fill in the name of the individual completing this form to ensure accountability.
13. After completing all necessary fields, save any changes before downloading, printing, or sharing the completed form.

Complete your documentation efficiently by filling out the OH CareSource Medicaid Provider Prior Authorization Request Form online.