1. Initial Recertification Change Cancel Recert: Enter previous PRIOR AUTH#. Change or Cancel: enter PRIOR AUTH# to be changed or canceled. PRIOR AUTH # / 3. Review Type (check one if applicable) 2. Date of Request (mm/dd/yyyy) / / Retrospective Prepayment Review (Date notified of eligibility / ) Retroactive MCO disenrollment 4. Member MMIS Number (12 digit Number): 5. Member Last Name: 6. Member First Name: 7. Date of Birth 8. Gender: (mm/dd/yyyy): Male / Female / 10. Treatment Setting 11. Primary Diagnosis Code/ Description: (enter up to 5) 9. a. NPI/API/Requesting Service Provider Name & ID Number: Outpatient 1. 2. Provider’s Office 3. 4. Home Intensive Outpatient 5. 12. 14. Member Information a. NPI/API/Referring Provider Name and ID Number: a. Responsible Party (if applicable): b. Relationship to Individual: 13. c. Date last seen by Physician: a. NPI/API Ordering Provider Name and ID Number:
1. Initial Recertification Change Cancel Recert: Enter previous PRIOR AUTH#. Change or Cancel: enter PRIOR AUTH# to be changed or canceled. PRIOR AUTH # 2. Date of Request (mm/dd/yyyy) / / 3. Review Type (check one if applicable) Retrospective Prepayment Review (Date notified of eligibility / / ) Retroactive MCO disenrollment 4. Member MMIS Number (12 digit Number): 5. Member Last Name: 6. Member First Name: 7. Date of Birth (mm/dd/yyyy): / / 8. Gender: Male Female 9. a. NPI/API/Requesting Service Provider Name & ID Number: 10. Treatment Setting Outpatient Provider’s Office Home Intensive Outpatient 11. Primary Diagnosis Code/ Description: (enter up to 5) 1. 2. 3. 4. 5. 12. a. NPI/API/Referring Provider Name and ID Number: 13. a. NPI/API Ordering Provider Name and ID Number: 14. Member Information a. Responsible Party (if applicable): b. Relationship to Individual: c. Date last seen by Physician: