№ lp_1_28977
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Character count: 6029
File size: 54 KB
This is a form used to submit prior authorization requests for Medicaid services including initial reviews, continued treatment reviews, retrospective reviews, and changes or cancellations.
Note:
Year
Topic:
Medicaid, Service Authorization
Document Type:
Form
Organization / Institution:
KePRO / SCDHHS
Target Audience:
Medicaid providers
Price: 8 / 10 USD
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The product description is provided for reference. Actual content and formatting may differ slightly.
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
Date:
August 1, 2023
Jurisdiction:
United States; South Carolina
Parties:
U.S. Department of Health and Human Services; Centers for Medicare & Medicaid Services; South Carolina Department of Health and Human Services
Document type:
Intergovernmental contract
Program:
Medicare-Medicaid integrated care demonstration
Subject matter:
Care coordination, enrollment, provider networks, quality improvement, and payment provisions
Covered entities:
Comprehensive Integrated Care Organizations (CICOs)
Regulatory framework:
Medicare and Medicaid
Effective period:
Demonstration years as specified in the contract
Governing law:
Applicable federal and state law
Jurisdiction:
State of Wisconsin
Issuing body:
Wisconsin Department of Health Services
Division:
Division of Medicaid Services
Program:
ForwardHealth
Legal reference:
Wis. Admin. Code § DHS 107.10(2)
Form number:
F-01430
Form version date:
December 2021
Document type:
Prior authorization medical form
Subject matter:
Prescription authorization for Xyrem and Xywav
Medical conditions referenced:
Narcolepsy with cataplexy, narcolepsy without cataplexy, idiopathic hypersomnia
Intended users:
Prescribers and pharmacy providers
Required attachments:
Medical records, sleep study results, ESS, MWT, MSLT
Regulatory requirement:
Xyrem and Xywav REMS Program compliance
Signature requirement:
Prescriber signature and date
Note:
Date
Topic:
Medicaid Waiver, CDC+, Background Screening
Document Type:
Application form
Organization / Institution:
Agency for Health Care Administration (AHCA)
Target Audience:
Applicants for Medicaid Waiver or CDC+ provider enrollment
Year:
2019
Region / City:
Santa Fe, New Mexico
Topic:
Medicaid, Healthcare Services, Procurement
Document Type:
Request for Proposals (RFP)
Agency / Institution:
New Mexico Human Services Department
Author:
Dr. David Scrase, Cabinet Secretary
Target Audience:
Contractors, Service Providers
Period of Validity:
Not specified
Approval Date:
August 21, 2019
Modification Date:
Not specified
Year:
2017
Region / City:
New York State
Document Type:
Form / Tool
Institution:
New York State Medicaid
Author:
Unknown
Target Audience:
Care Managers, Medicaid Health Professionals
Validity Period:
Not specified
Approval Date:
Not specified
Date of Last Update:
Not specified
Year:
2026
Region / City:
United States
Topic:
Federal procurement and contract management
Document Type:
Policy/Guidance
Agency / Institution:
GSA (General Services Administration)
Author:
GSA
Target Audience:
Contractors, Government Agencies
Period of Validity:
Ongoing
Approval Date:
N/A
Modification Date:
N/A
Year:
2026
Region / City:
N/A
Subject:
Prior authorization requirements for lower extremity endovascular procedures
Document type:
Checklist
Organization:
N/A
Author:
N/A
Target audience:
Healthcare providers
Period of validity:
N/A
Approval date:
N/A
Date of amendments:
N/A
Year:
2023
Region / City:
United Kingdom
Topic:
Accreditation of Prior Learning
Document Type:
Standard Operating Procedure
Institution:
Quality Assurance
Author:
Nicola Bell
Target Audience:
Academic staff, students
Period of Validity:
Until September 2025
Approval Date:
04/09/2023
Review Date:
September 2025
Date of Changes:
04/09/2023
Year:
Not specified
Region / City:
Not specified
Topic:
Prior Authorization Request
Document Type:
Letter
Organization / Institution:
Kyowa Kirin Inc.
Author:
Not specified
Target Audience:
Medical professionals, insurance providers
Period of Effectiveness:
Not specified
Approval Date:
Not specified
Date of Changes:
Not specified
Year:
2023
Region / City:
New York State
Theme:
Cultural Resource Management
Document Type:
Template for Historic Preservation Finding Document
Agency / Institution:
New York State Department of Transportation (NYSDOT)
Author:
Not specified
Target Audience:
Project managers, cultural resource coordinators, historical preservation professionals
Period of Validity:
Not specified
Approval Date:
Not specified
Date of Changes:
Not specified