Instructions to Complete Ancillary Service Authorization Request For Physical Therapy, Speech Therapy, Occupational Therapy

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1 Western Oregon Advanced Health, LLC. P.O. Box 1096 Coos Bay, OR Instructions to Complete Ancillary Service Authorization Request For Physical Therapy, Speech Therapy, Occupational Therapy Provider is responsible for submitting all information in the top portion of the Ancillary Service Authorization Request form along with required documentation. Initial therapy evaluations do not require prior authorization, unless provided by an out-of-area provider in which a referral is required. Required Documentation: MD s current prescription or signed order PT/ST/OT Evaluation PCP note, Specialist Note, Other diagnostic testing results; all of these items are optional Fax completed form and documentation to WOAH s Medical Management Department at (541) If you have questions regarding this form or other related questions, please contact WOAH s Medical Management Department at (541) To complete form, please follow these instructions: Requesting Provider: Phone #: Fax #: Member Name: DOCS ID #: DOB: Prescribing MD: PCP: Requested Date of Service: ICD-10 Code(s): Item/Services Requested: Enter the name of the Therapy Provider requesting authorization Enter the office phone number of the requesting Therapy Provider Enter the office fax number of the requesting Therapy Provider Enter the full name of the OHP Member, including middle initial if known. (Required field) Enter the OHP ID number for the Member Enter Member s date of birth Enter the name of the physician who prescribed therapy Enter the name of the Member s Primary Care Physician Enter the date duration needed to complete the therapy (Required field > ) Enter the ICD-10 codes for the diagnoses that relate to the requested services. Diagnosis must be coded to the highest level of specificity. Enter the description of the therapy or modality being requested

2 Codes and applicable modifiers: See below - Outpatient/Non-Hospital based: Enter the CPT codes for each therapy and/or modality being requested - Outpatient/Hospital based: Enter the Revenue Code and correlating CPT code for each individual therapy and/or modality being requested. - Skilled Nursing Facility: Enter the Revenue Code and correlating CPT code for each individual therapy and/or modality being requested. - Home Health: Please use the Home Health Authorization Request form Quantity Requested: Documents attached: If Yes, please specify: Comments: Signature of Requesting Provider: Date: Enter the quantity of each type of therapy being requested Mark the appropriate box to indicate if the required documentation is attached. (*Required documentation = See above) Indicate what documentation is being submitted with the request form. Add any additional information that is pertinent to the request. The Non-Physician Provider who is requesting therapy services must sign the authorization request. Enter the date the Non-Physician Provider signed the Referral Request.

3 Instructions to Complete Ancillary Service Authorization Request For Durable Medical Equipment (DME) or Oral Enteral Supplements Requesting Provider is responsible to submitting all information in the top area of the form. This form is used for submitting prior authorization requests only. For Referral/PA physician services use the Physician Referral/Prior Authorization Request form. Required Documentation: DME: DME requiring Certificates of Medical Necessity (CMN s) can be submitted with the dispensing RX. The request will be pended waiting the receipt of CMN or other information as requested. Oral Enteral Supplements: Criteria letter must be submitted with request as well as the prescription. Units submitted must be in calories, not cans per day. Disclaimer: Approval does not assure payment, which also depends on patient eligibility on date of service, contract terms, and compliance with rules, regulations and policies of WOAH and/or OHA as applicable. Fax completed form and documentation to WOAH s Medical Management Department at (541) If you have questions regarding this form or other related questions, please contact WOAH s Medical Management Department at (541) To complete form, please follow these instructions: Requesting Provider: Phone #: Fax #: Member Name: DOCS ID#: DOB: Prescribing MD: PCP: Requested Dates: Enter the name of the provider that is submitting the request Enter the phone of the requesting provider Enter the fax number of the requesting provider Enter the full name of the OHP Member, including middle initial, if known (Required field) Enter the Member s OHP ID# (Required field) Enter the Member s date of birth Enter the physician who prescribed the equipment Enter the PCP for the OHP member, if known. Leave blank if unknown. Enter the requested dates to provide equipment or services. ICD-10 Code(s): Item/Service Requested: (Required field > ) Enter the ICD-10 codes for the diagnoses that relate to the requested services. Diagnosis must be coded to the highest level of specificity. Enter the description of the item. (e.g. pant liners)

4 Codes and applicable modifiers: Quantity Requested: Unit of Measure: Documents attached: If Yes, please specify: Other information: Signature of Requesting Provider: Date: Enter the valid HCPCS code for the item requested and modifier. Modifier for contracted items as in contracts or for Purchase Items = NU, Rental Items = RR Enter quantity of item or service requested. Enter units in accordance as utilized in billing process. (e.g. per box, each, 100 calories or per pair) Mark the appropriate box to indicate if the required documentation is attached. (**Required documentation = See above) Indicate what documentation is being submitted with the request form Enter any comments or in the case of non-specific HCPCS codes list the RETAIL PRICE for the item. A description of the item must accompany these requests and in certain items the suppliers invoice may be requested. The person filling out the request must sign the form. Enter the date the request is signed.

5 Authorization #: Western Oregon Advanced Health, LLC. P.O. Box 1096, Coos Bay, OR Voice: Fax: TTY: Ancillary Service Authorization Request For questions call: Fax Completed Form and Records to ** PLEASE NOTE: INCOMPLETE FORMS WILL DELAY THE AUTHORIZATION PROCESS ** Member s primary health insurance: WOAH OHP Dual Eligible - has Medicare and WOAH OHP Member Name: Plan ID #: DOB: / / Requesting Provider: Phone #: Fax #: Prescribing MD: PCP: Requested Dates: / / to / / ICD-10 Code: (Required: > ) Item/Service Requested Codes and applicable modifiers Quantity Requested Unit of Measure (UOM) For Internal use Only Units requested must be in accordance with standard unit of measure (UOM) utilized for billing purposes. Documents Attached?: Yes No List Documents: Other Information: Person Completing Form: Signature of Requesting Provider: Date / / Disclaimer: Prior Authorization does not assure payment, which also depends on patient eligibility on date of service, contract terms, and compliance with rules, regulations and policies of DMAP, Medicare and WOAH as applicable. For Internal Use Only: Notes: Contracted Provider: Yes No Approved as requested Approved dates: / / to / / Modified Request: MM Staff Signature: Set Unit Limit: Yes No Faxed via: System: Manual: Unit Count: Date: / / Initials: Denial Reason Medical Directors Signature (For Denied Services): D PII MC Date: / / NOA Date: / / Initials:

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