Complex Care Provider Guide (PowerPoint Format)
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This PowerPoint Presentation explains how to submit a Complex Care Add-on Request, list the required forms and explains the Electronic Prior Authorization (e-PA) process. |
Prior Authorization Required Forms for requesting Complex Care for recipients in an ICF/IID facility (PDF Format)
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This form is used to request Complex Care add-on rates in an ICF/IID. |
Prior Authorization Request Form for Chemotherapy Drug J9042 (PDF Format)
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NEW Modified PA-01 for use in requesting requesting Complex Care for recipients in an ICF/IID facility. |
PA-01
Prior Authorization Form and Instructions (PDF Format)
(last modified 08/2021) |
The PA-01 prior authorization includes
instructions for the following PA types: 01 Outpatient Surgery Performed
Inpatient Hospital, 05 Rehabilitation Therapy, 09 DME Equipment & Supplies,
99 Outpatient Surgery Performed Inpatient (CPT Procedures) & all other
Specialized CPT Procedures. |
Pediatric Hospital Bed Evaluation Form (PDF Format)
(revised 02/2020)
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This form is used to evaluate the medical necessity for pediatric hospital beds. |
Standing Frame Evaluation Form (PDF Format)
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This form is used to evaluate the medical necessity for standing frame equipment. |
| PA-02 Form (PDF Format) |
When prior authorizing outpatient
rehabilitation services, the PA-02 is required in conjunction with the
PA-01. It should be completed and submitted with the PA-01.
(Discontinued in 08/10)
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| PA-07 Form (PDF Format) |
The PA-07 form is used by Home Health
agencies to request extended nursing care for eligible recipients under age 21.
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| PA-14 Form (PDF Format) |
The PA-14 form is designed for prior
authorization of personal care services. (revised May 2019)
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| PA-15 Form (PDF Format) |
The PA-15 form is designed for prior authorization
of Air Ambulance services.
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| PA-16 Form and Instructions (PDF Format) |
The PA-16 Form is used for prior authorization of Pediatric Day Health Care (PDHC) services. |
| Prescription Request Form for Disposable Incontinence Products (PDF Format) |
Providers may submit a completed prescription
request form for disposable incontinence products or a physician's
prescription, along with the required documentation. Click to view the
Medical Criteria for Incontinence Products
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| Prior Authorization Request for Transplant Form – TP-01 (PDF Format) |
This form must be completed by the provider when requesting prior authorization for transplant.
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