Get Pa Ma 97 2005-2026
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How to fill out the PA MA 97 online
The PA MA 97 is an essential document for requesting outpatient services authorization from the Commonwealth of Pennsylvania. This guide provides clear instructions on how to complete the form accurately and efficiently, helping users navigate the process with ease.
Follow the steps to complete the PA MA 97 form online.
- Click ‘Get Form’ button to obtain the PA MA 97 and open it in your preferred editor.
- Indicate the type of request by checking the appropriate box for either Prior Authorization or 1150 Waiver. Remember to select only one option.
- Complete the Patient Information section (items 3-6) using details from the Eligibility Verification System (EVS), including the recipient number, name, birthdate, and sex.
- Fill in the Provider/Prescriber Information section (items 7-11), entering the provider's name, ID, and information about any group or payee receiving the payment.
- If applicable, complete the Referring Practitioner/Prescriber section (items 12-15) by providing their name, license number, and contact information.
- In the Primary Diagnosis section (item 16), enter the primary diagnosis, and include the corresponding ICD-9-CM code in item 17. If there is a secondary diagnosis, fill out items 18 and 19.
- Detail the Requested Services in items 20A-29. Describe the services required, include procedure codes when necessary, and provide quantity and duration of services requested.
- Complete the alternative methods tried (item 27) and indicate the patient's current residential status (item 28).
- Provide a narrative description of symptoms related to the service request (item 29). Ensure you document medical justifications.
- Indicate the number of attachments in item 30. If applicable, complete items 31 and 32 for initial or resubmitted requests.
- Secure the required signatures in items 33-36 from the patient and practitioner, ensuring all dates are filled in correctly.
- Once all sections are completed, you can save your changes, download, print, or share the PA MA 97 form as needed.
Complete your PA MA 97 online today to ensure timely processing of your outpatient services request.
In Pennsylvania, income eligibility for medical assistance is determined by household size and specific income limits. Generally, individuals and families must meet certain thresholds based on federal poverty guidelines. To ensure you qualify, it’s advisable to review the latest income limits and consider all sources of income. Using resources like USLegalForms can help clarify eligibility and prepare your application.
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