№ lp_1_2_38031
File format: docx
Character count: 2536
File size: 42 KB
The document is a fax form used to request prior authorization for Medicaid Targeted Case Management services.
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
Price: 8 / 10 USD
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The product description is provided for reference. Actual content and formatting may differ slightly.
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
Note:
Year
Theme:
Prior Authorization
Document Type:
Fax Form
Organization / Institution:
Acentra Health, SCDHHS
Target Audience:
Medicaid Providers
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
Year:
2024
Region / City:
Toronto, ON
Subject:
Girl Guides of Canada Activity Participation
Document Type:
Permission Form
Organization:
Girl Guides of Canada
Author:
Girl Guides of Canada
Target Audience:
Parents/Guardians
Period of Activity:
May 24, 2024
Approval Date:
N/A
Modification Date:
N/A
Description:
A permission form for parents/guardians to authorize their child to participate in the Girl Guides of Canada event, GirlJam 2024, including risk acknowledgment and emergency contact information.
Note:
with “[Your COG’s name] 205(j) Grant Proposal” in the subject line by midnight on Thursday, September 18, 2025.
Year:
2025
Region / City:
North Carolina, USA
Subject:
Water Quality Grant Proposal
Document Type:
Application Form
Organization:
North Carolina Department of Environmental Quality
Author:
Robin Hoffman
Target Audience:
Local government agencies, organizations, and project managers
Period of validity:
September 18, 2025
Approval Date:
Not specified
Amendment Date:
Not specified
Year:
2015
Region / City:
Arctic-Yukon-Kuskokwim
Topic:
Chinook Salmon Conservation Research
Document Type:
Invitation for Research Proposals
Organ / Institution:
AYK SSI Program
Author:
AYK SSI Program Management
Target Audience:
Researchers and Academic Institutions
Period of Action:
2015–2018
Approval Date:
January 27, 2015
Modification Date:
None
Year:
2025/2026
Region/City:
Australia
Topic:
Indigenous Health Reporting
Document Type:
Screencast Instructions
Organ/Institution:
Health Data Portal
Author:
Not specified
Target Audience:
Health services required to submit TIS Performance Reports
Period of Validity:
January 1 and July 1 each year
Approval Date:
Not specified
Date of Changes:
Not specified
Note:
Year
Topic:
Packaging Standards
Document type:
Form
Target audience:
Manufacturers, suppliers, and packaging designers
Contextual description:
This document is a form used for submitting packaging components, inks, and dyes for regulatory review, ensuring compliance with environmental and safety standards.
Year:
2023
Region / city:
CAISO
Theme:
Interconnection process improvements
Document type:
Discussion paper
Author:
EDF-R
Target audience:
Stakeholders involved in interconnection process
Period of action:
Not specified
Approval date:
Not specified
Date of changes:
Not specified
Year:
2023
Region / City:
Kiribati
Topic:
Procurement
Document Type:
Request for Proposal
Organization:
Ministry of Finance and Economic Development
Author:
Ministry of Education
Target Audience:
Tenderers
Period of validity:
Until final submission deadline
Approval Date:
N/A
Date of Amendments:
N/A
Note:
Year
Subject:
Accreditation Process
Document Type:
Instructional Manual
Organ / Institution:
BABCP
Target Audience:
Health professionals undergoing accreditation