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Home > Provider > Prior Authorization (PA) - Provider Instruction Sheets and Prior Authorization Forms

Prior Authorization (PA) - Provider Instruction Sheets and Prior Authorization Forms

Prior Authorization Provider Instruction Sheets

General Information In_State Services
Dental Services Out Of State (OOS) Services
Durable Medical Equipment Podiatry
Early Periodic Screening Diagnosis and Treatment (EPSDT) Option Transportation
Hearing Aids and Services Vision
Prior Authorization Forms

General Information

   
  • PA Process Information Sheet
 (.doc) (.pdf)
     

Dental Services

   
  • Full/Partial Dentures
(.doc) (.pdf)
  • Procedures
 (.doc) (.pdf)
  • Orthodontic Procedures
(.doc) (.pdf)
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Durable Medical Equipment (DME)

   
  • General Instructions for DME
(.doc) (.pdf)
  • DME Replacement Part Letter
 (.doc) (.pdf)
  • DME Replacement Part Document
 (.doc) (.pdf)
  • Apnea Monitor
 (.doc) (.pdf)
  • Augmentative Communication Device/System
(.doc) (.pdf)
  • Blood Glucose Monitor for Home Use
(.doc) (.pdf)
  • Bone Growth Stimulator
 (.doc) (.pdf)
  • Cochlear Implant Device
    
    • Device
(.doc) (.pdf)
    • Supplies/Repairs
(.doc) (.pdf)
  • CPAP and BiPAP
(.doc) (.pdf)
  • Home Traction
(.doc) (.pdf)
  • Hospital Beds
(.doc) (.pdf)
  • Intermittent Positive Pressure Breathing Equipment
 (.doc) (.pdf)
  • Infusion Pump
   
    • External for Diabetes
(.doc) (.pdf)
    • External
(.doc) (.pdf)
    • Implantable
(.doc) (.pdf)
  • Negative Pressure wound Therapy
(.doc) (.pdf)
  • Nutrition Therapy (Enteral and Parenteral)
(.doc) (.pdf)
  • Orthotic Devices
 (.doc) (.pdf)
  • Oxygen
 (.doc) (.pdf)
  • Pneumatic Compression Devices
 (.doc) (.pdf)
  • Power Operated Vehicles
 (.doc) (.pdf)
  • Seasonal Affective Disorder (SAD) Lamps
(.doc) (.pdf)
  • Seat Lift Mechanisms
 (.doc) (.pdf)
  • Wheelchairs
    
    • Manual
 (.doc) (.pdf)
    • Power
 (.doc) (.pdf)
    • Specialty
 (.doc) (.pdf)
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Early Periodic Screening, Diagnosis and Treatment (EPSDT) Option

   
  • Optional Treatment
 (.doc) (.pdf)
     

Hearing Aids and Services

    
  • Hearing Aids and Services
 (.doc) (.pdf)
     

In-State Services

   
  • Botox
 (.doc) (.pdf)
  • Breast Reconstruction
 (.doc) (.pdf)
  • Breast Reduction and Mastopexy
(.doc) (.pdf)
  • Circumcision
 (.doc) (.pdf)
  • Cosmetic procedures
(.doc) (.pdf)
  • Eyelid Surgery
(.doc) (.pdf)
  • Gastric Bypass or Gastroplasty
 (.doc) (.pdf)
  • Hyperbaric Oxygen
 (.doc) (.pdf)
  • Hysterosalpingograms
 (.doc) (.pdf)
  • Infertility Services
  • Removal of excess Skin and Subcutaneous Tissue of the Abdomen
 (.doc) (.pdf)
  • Supprelin LA 09/25/2008
 (.doc) (.pdf)
  • Synvisc/Hyalgan/Orthovisc
 (.doc) (.pdf)
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Out of State (OOS) Services

   
  • Instruction Sheet
(.doc) (.pdf)
     

Podiatry

    
  • Podiatry Letter to Providers
(.doc) (.pdf)
  • Bunion Surgery
 (.doc) (.pdf)
  • Endoscopic Plantar Fasciotomy
 (.doc) (.pdf)
  • Selected Foot Surgery
 (.doc) (.pdf)
  • Toe Joint Fusion
 (.doc) (.pdf)
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Transportation

    
  • Transportation Procedures
(.doc) (.pdf)
     

Vision Services

   
  • Contact Lenses
(.doc) (.pdf)
  • Eyeglasses
 (.doc) (.pdf)
  • Low Vision Aids
(.doc) (.pdf)
  • Medical Eye Care PA Summary
(.doc) (.pdf)
  • Medical Eye Care Benefit
(.doc) (.pdf)
     
     

Prior Authorization Forms

   
   
 
  • DME Supplies/Equipment Prior Authorization Form (MA-56)
(.pdf)
 
  • Supprelin LA 09/25/08 Prior Authorization Form
 (.pdf)

 

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