now require any Medicaid Provider submitting Prior “KePRO/SCDHHS Authorizations using their National Provider Identifier (NPI) to provide their 9 digit zip code. If you do not know your 9 digit zip codes then please visit: ” Submit fax request for Prior Authorization to: 1-855-300-0082 Requests may be submitted up to 30 days prior to scheduled procedures/services, provided the Member is eligible. Recert: Enter previous PA#. Change or 1. Initial Recertification Change Cancel PA # Cancel: Enter PA# to be changed or canceled. Date of request: (mm/dd/yyyy) Review Type: (Please check one if applicable) / / Prior Authorization Retrospective Review (Date notified of eligibility / / Member Medicaid ID Number Member Last Name: Member First Name: (10 Digit number): Date of Birth: (mm/dd/yyyy) Sex: NPI Submitting Provider Name: / / Male Medicaid ID Number: Female c. 9 digit Zip Code (Mandatory) Treatment Setting /Service Surgical Admission: Type: NPI Facility Name: Yes No Inpatient 9 Digit Zip Code: (mandatory) Admission Date: Admission Status: Primary Diagnosis Code/Description: (mm/dd/yyyy) Elective Emergency / / 16. Service type: Inpatient Freestanding Inpatient Psychiatric under 21 or 65 and older 17. Number of Days Requested: 18. Attending Physician NPI: 19. Procedure Code/Description (if applicable): 20. Procedure Scheduled Date: (mm/dd/yyyy) / /
“KePRO/SCDHHS now require any Medicaid Provider submitting Prior Authorizations using their National Provider Identifier (NPI) to provide their 9 digit zip code. If you do not know your 9 digit zip codes then please visit: ” Submit fax request for Prior Authorization to: 1-855-300-0082 Requests may be submitted up to 30 days prior to scheduled procedures/services, provided the Member is eligible. 1. Initial Recertification Change Cancel Recert: Enter previous PA#. Change or Cancel: Enter PA# to be changed or canceled. PA # Date of request: (mm/dd/yyyy) / / Review Type: (Please check one if applicable) Prior Authorization Retrospective Review (Date notified of eligibility / / Member Medicaid ID Number (10 Digit number): Member Last Name: Member First Name: Date of Birth: (mm/dd/yyyy) / / Sex: Male Female NPI Submitting Provider Name: Medicaid ID Number: c. 9 digit Zip Code (Mandatory) NPI Facility Name: 9 Digit Zip Code: (mandatory) Treatment Setting /Service Type: Inpatient Surgical Admission: Yes No Admission Date: (mm/dd/yyyy) / / Admission Status: Elective Emergency Primary Diagnosis Code/Description: 16. Service type: Inpatient Freestanding Inpatient Psychiatric under 21 or 65 and older 17. Number of Days Requested: 18. Attending Physician NPI: 19. Procedure Code/Description (if applicable): 20. Procedure Scheduled Date: (mm/dd/yyyy) / /