ࡱ> ehbcd ,bjbj΀ j'I842 %%%%G( * +r3t3t3t3t3t3t36o9@t3+%("G(++t3%%fU4...+X%%r3.+r3..V0 1%/03+1 ^3k404109,x9191h++.+++++t3t3.+++4++++9+++++++++ : MISSOURI DEPARTMENT OF SOCIAL SERVICES MO HEALTHNET DIVISION PRIOR AUTHORIZATION REQUESTReturn to: Infocrossing Healthcare Services, Inc. PO Box 5700 Jefferson City, MO 65102Authorization approves the medical necessity of the requested service only. It does not guarantee payment, nor does it guarantee that the amount billed will be the amount reimbursed. The participant must be MO HealthNet Eligible on the date of service or date the equipment or prosthesis is received by the participant. SEE REVERSE SIDE FOR INSTRUCTIONS.I. GENERAL INFORMATION1.  FORMTEXT      2. NAME (LAST, FIRST, M.I.)  FORMTEXT      3. DATE OF BIRTH  FORMTEXT      4. ADDRESS (STREET. CITY, STATE, ZIP CODE)  FORMTEXT      5. MO HEALTHNET NUMBER  FORMTEXT      6. PROGNOSIS  FORMTEXT      7. DIAGNOSIS CODE  FORMTEXT      8. DIAGNOSIS DESCRIPTION  FORMTEXT      9. NAME AND ADDRESS OF FACILITY WHERE SERVICES ARE TO BE RENDERED IF OTHER THAN HOME OR OFFICE  FORMTEXT      II. HCY (EPSDT) SERVICE REQUEST (MAY REQUIRE PLAN OF CARE)10. DATE OF HCY SCREEN  FORMTEXT      11. SCREENING  FORMCHECKBOX  FULL  FORMCHECKBOX  INTERPERIODIC  FORMCHECKBOX  PARTIAL12. TYPE OF PARTIAL HCY SCREEN  FORMTEXT      13. SCREENING PROVIDER NAME  FORMTEXT      14. PROVIDER IDENTIFIER  FORMTEXT      15. TELEPHONE NUMBER  FORMTEXT      III. SERVICE INFORMATIONFOR STATE USE ONLY16. REF. NO17 PROCEDURE CODE18. MODIFIERS19. FROM20. THROUGH21. DESCRIPTION OF SERVICE/ITEM22. QTY. OR UNITS23. AMOUNT TO BE CHARGEDAPPR.DENIEDAMOUNT ALLOWED IF PRICED BY REPORT(1) FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT      (2) FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT      (2) FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT      (4) FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT      (5) FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT      (6) FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT      (7) FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT      (8) FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT      (9) FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT      (10) FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT      (11) FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT      (12) FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT      24. DETAILED EXPLANATION OF MEDICAL NECESSITY FOR SERVICES/EQUIPMENT/PROCEDURE/PROSTHESIS (ATTACH ADDITIONAL PAGES IF NECESSARY)  FORMTEXT      IV. PROVIDERV. PRESCRIBING/PERFORMING PRACTITIONER25. PROVIDER NAME (AFFIX LABEL HERE)  FORMTEXT      29. NAME  FORMTEXT      30. TELEPHONE  FORMTEXT       26. ADDRESS  FORMTEXT      31. ADDRESS  FORMTEXT       FORMTEXT      FAX NUMBER  FORMTEXT      32. DATE DISABILITY BEGAN  FORMTEXT      33. PERIOD OF MEDICAL NEED IN MONTHS  FORMTEXT      27. MO HEALTHNET PROVIDER IDENTIFIER  FORMTEXT      TAXONOMY  FORMTEXT      I certify the information given in Sections I and III of this form is true, accurate, and complete.28. SIGNATUREDATE34. SIGNATURE OF PRESCRIBING PHYSICIAN/PRACTITIONERDATEVI. FOR STATE OFFICE USE ONLYDENIAL REASON(S): REFER TO FIELD 16 ABOVE BY REFERENCE NUMBERS (REF. NO.)  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GENERAL INFORMATION - To be completed by the provider requesting the prior authorization. Leave Blank Participant's Name - Enter the participant's name as it appears on the MO HealthNet ID card. Enter the participant's current address. Date of Birth - Enter the participant's date of birth. Address - Enter the participant's address, city, state, and zip. MO HealthNet Number - Enter the participant's 8-digit MO HealthNet identification number as shown on the MO HealthNet identification card or county letter of eligibility. Prognosis - Enter the participant's prognosis. Diagnosis Code - Enter the diagnosis code(s). Diagnosis Description - Enter the diagnosis description. If there is more than one diagnosis, enter all descriptions appropriate to the services being requested. Name and address of the facility where services are to be rendered if service is to be provided other than home or office. II. HCY SERVICE REQUEST (Plan of care may be required, see your provider manual) Date of HCY Screen - Enter the date the HCY Screen was done. Screening - Check whether the screening performed was FULL, INTERPERIODIC, OR PARTIAL. Type of Partial HCY Screen - Enter the type of partial HCY Screen that was performed. (e.g., Vision, Hearing, etc.) Screening Provider Name - Enter the provider's name who performed the screening. Provider Identifier - Enter the provider's NPI number who performed the screening. Telephone Number - Enter the screening provider's telephone number including the area code. III. SERVICE INFORMATION Ref. No. - (Reference Number) A unique designator (1-12) identifying each separate line on the request. Procedure Code - Enter the procedure code(s) for the services being requested. Modifier - Enter the appropriate modifier(s) for the services being requested. From - Enter the from date that services will begin if authorization is approved (mm/dd/yy format). Through - Enter the through date the services will terminate if authorization is approved (mm/dd/yy format). Description of Service/Item - Enter a specific description of the service/item being requested. Quantity or Units - Enter the quantity or units of service/item being requested. Amount to be Charged - Enter the amount to be charged for the service. Detailed Explanation of Medical Necessity of the service, equipment/procedure/prosthesis, etc. Attach additional page(s) as necessary. Do not use another Prior Authorization Form. IV. PROVIDER REQUESTING PRIOR AUTHORIZATION Provider Name - Attach a MO HealthNet provider label or enter the requested provider's information exactly as it appears on the label. Address - If a MO HealthNet provider label is not used, enter the complete mailing address in this field. MO HealthNet Provider Identifier - If a MO HealthNet provider label is not used, enter the provider's MO HealthNet identification number. Signature/Date - The provider of services should sign the request and indicate the date the form was completed. (Check your provider manual to determine if this field is required.) V. PRESCRIBING/PERFORMING PRACTITIONER This section must be completed for services which require a prescription such as Durable Medical Equipment, Physical Therapy, or for services which will be prescribed by a physician/practitioner that require Prior Authorization. Check your provider manual for additional instructions. Name - Enter the name of the prescribing/performing practitioner. Telephone Number - Enter the prescribing/performing practitioner telephone number including area code. Address - Enter the address, city, state, and zip code. Date Disability Began - Enter the date the disability began. For example, if a disability originated at birth, enter date of birth. Period of Medical Need in Months - Enter the estimated number of months the participant will need the equipment/services. 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