№ lp_1_2_35445
File format: docx
Character count: 9727
File size: 59 KB
The document is a fax submission form for Medicaid providers to request prior authorization for services, including mental health counseling, therapies, and other medical treatments, detailing specific provider and patient information required.
Note:
Year
Theme:
Prior Authorization
Document Type:
Fax Form
Organization / Institution:
Acentra Health, SCDHHS
Target Audience:
Medicaid Providers
Price: 8 / 10 USD
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Year:
Not specified
Region / jurisdiction:
South Carolina
Program:
Medicaid
Document type:
Administrative form
Purpose:
Prior authorization review for inpatient services
Submitting method:
Fax
Fax number:
1-855-300-0082
Responsible organizations:
KePRO; South Carolina Department of Health and Human Services
Provider identification:
National Provider Identifier (NPI); Medicaid ID
Mandatory provider location data:
9-digit ZIP code
Review types:
Initial; Recertification; Change; Cancel; Retrospective review
Service setting:
Inpatient; freestanding inpatient psychiatric
Population focus:
Medicaid members; psychiatric services for children under 21 and adults 65 and older
Eligibility window:
Up to 30 days prior to scheduled services
Clinical information required:
Diagnosis; severity of illness; intensity of services
Approval process:
Subject to medical necessity and eligibility verification
Year:
N/A
Region / City:
N/A
Topic:
Medicaid, Prior Authorization, Targeted Case Management
Document Type:
Fax Request Form
Agency / Institution:
Acentra Health
Author:
N/A
Target Audience:
Healthcare providers, Medicaid service providers
Effective Period:
N/A
Approval Date:
N/A
Amendment Date:
N/A
Organization:
Acentra Health
Program:
South Carolina Department of Health and Human Services (SCDHHS)
Document type:
Administrative form
Purpose:
Prior authorization, recertification, change, or cancellation of outpatient Medicaid services
Submission method:
Fax
Fax number:
1-855-300-0082
Applicable services:
Mental Health Counseling, Therapies (PT, OT, SP), DME, Home Health, Hospice, Autism Spectrum Disorder
Provider identification:
National Provider Identifier (NPI) with 9-digit ZIP Code
Member identification:
Medicaid ID Number
Geographic scope:
South Carolina
Review types:
Initial, Recertification, Change, Cancel, Retrospective Prepayment Review
Governing criteria:
SCDHHS and InterQual guidelines
Associated system:
Atrezzo Connect
Submission timing:
Up to 30 days prior to scheduled services, excluding weekends and holidays
Year:
2026
Region / City:
South Carolina
Theme:
Medicaid, Prior Authorization
Document Type:
Form
Organization / Institution:
KEPRO-SCDHHS
Author:
KePRO
Target Audience:
Medicaid providers
Period of Validity:
Ongoing
Approval Date:
Not specified
Date of Changes:
Not specified
Year:
2019
Region / City:
North Carolina
Subject:
Data Privacy and Security
Document Type:
Best Practices Guide
Institution:
North Carolina Department of Public Instruction
Author:
Division of School Data, Research and Federal Policy
Target Audience:
NC Department of Public Instruction (DPI) staff, school and LEA staff
Period of Validity:
Ongoing
Approval Date:
August 30, 2019
Date of Modifications:
Not specified
Note:
Year
Year:
Not specified
Region / City:
Western Australia
Theme:
Healthcare, Continence Management
Document Type:
Referral Form
Organization / Institution:
Silver Chain
Author:
Not specified
Target Audience:
Medical practitioners, healthcare facilities, and clients
Period of validity:
Not specified
Approval Date:
Not specified
Date of amendments:
Not specified
Year:
2007
Region / City:
USA, Malaysia, Australia
Theme:
Telephony, Fax Solutions, Integration
Document Type:
Product Information
Organization / Institution:
FaxCore Software
Author:
FaxCore Software
Target Audience:
Small and Medium Enterprises (SMEs)
Period of Validity:
N/A
Approval Date:
N/A
Date of Changes:
N/A
Year:
2014
Region / City:
California
Document Type:
Compliance Notice
Organization:
Signature Networks PLUS
Author:
Signature Networks PLUS
Target Audience:
Medical Providers, Physician Offices
Period of Action:
Starting January 1, 2014
Approval Date:
Not specified
Amendment Date:
Not specified
Year:
Not provided
Region / City:
Greenville, NC
Topic:
Not specified
Document Type:
Contact Information
Organization / Institution:
East Carolina University
Author:
Not provided
Target Audience:
Not specified
Effective Period:
Not specified
Approval Date:
Not provided
Amendment Date:
Not provided
Note:
Year
Topic:
Medicaid Services, People with Disabilities, Case Management
Document Type:
Guide
Organization / Institution:
Oregon Department of Human Services (ODHS)
Target Audience:
Case Managers, Social Workers, Healthcare Providers
Year:
2024
Region / City:
Oregon
Theme:
Medicaid, Long-Term Services & Supports
Document Type:
Checklist
Agency / Institution:
Oregon Department of Human Services (DHS)
Author:
Not specified
Target Audience:
Eligibility Case Managers, Oregon ACCESS users
Period of Action:
Not specified
Approval Date:
9/11/24
Modification Date:
9/11/24
Year:
2023
Region / City:
United States
Topic:
Medicaid, 340B Program
Document Type:
Instructional Form
Organization:
HRSA (Health Resources and Services Administration)
Author:
HRSA
Target Audience:
Covered entities, contract pharmacies, Medicaid providers
Effective Period:
Ongoing
Approval Date:
March 5, 2010
Modification Date:
December 12, 2014
Year:
2023
Region / City:
Oregon
Topic:
Medicaid, Health Care Programs
Document Type:
Guide
Agency / Institution:
Oregon Project Independence
Author:
Oregon Department of Human Services
Target Audience:
Health care providers, Medicaid recipients
Effective Period:
Ongoing
Approval Date:
N/A
Amendment Date:
N/A
Year:
2023
Region / city:
Washington State
Topic:
Medicaid Alternative Care (MAC), Tailored Supports for Older Adults (TSOA), Family Caregivers
Document type:
Policy Description
Organ / institution:
Washington State Department of Social and Health Services (DSHS)
Author:
Resa Lee-Bell, Adrienne Cotton
Target audience:
Unpaid family caregivers, healthcare professionals, Medicaid recipients
Period of validity:
Not specified
Approval date:
Not specified
Date of changes:
Not specified
Note:
Description of the document
Year:
2023
Region / City:
Illinois
Theme:
Mental Health, Crisis Assessment
Document Type:
Assessment Tool
Institution:
Illinois Medicaid
Author:
Unknown
Target Audience:
Mental Health Professionals
Period of Validity:
Ongoing
Approval Date:
Unknown
Date of Changes:
Unknown
Note:
Year
Theme:
Adoption Assistance
Document Type:
Annual Assurance Form
Agency / Organization:
Ohio Department of Children and Youth
Target Audience:
Adoptive Parents, Eligibility Determiners
Note:
Year
Region / City:
Illinois
Document Type:
Comprehensive needs assessment
Organization / Agency:
Illinois Medicaid
Target Population:
Medicaid-eligible individuals
Assessment Type:
Initial / Update / Re-assessment
Sections Included:
General Information, Established Supports, Trauma Exposure, Presenting Problem and Impact on Functioning, Safety
Data Collected:
Personal information, demographics, caregiver details, trauma history, behavioral and emotional needs, life functioning, risk behaviors
Scoring System:
0–3 scale for CANS items
Modules Reference:
IM+CANS Modules Addendum
Year:
Not specified
Region / jurisdiction:
South Carolina
Program:
Medicaid
Document type:
Administrative form
Purpose:
Prior authorization review for inpatient services
Submitting method:
Fax
Fax number:
1-855-300-0082
Responsible organizations:
KePRO; South Carolina Department of Health and Human Services
Provider identification:
National Provider Identifier (NPI); Medicaid ID
Mandatory provider location data:
9-digit ZIP code
Review types:
Initial; Recertification; Change; Cancel; Retrospective review
Service setting:
Inpatient; freestanding inpatient psychiatric
Population focus:
Medicaid members; psychiatric services for children under 21 and adults 65 and older
Eligibility window:
Up to 30 days prior to scheduled services
Clinical information required:
Diagnosis; severity of illness; intensity of services
Approval process:
Subject to medical necessity and eligibility verification