INSTRUCTIONS Section I: Participant Information Recipient Identification # Enter the that appears on the IL Medicaid – Participant’s number identification card. Participant Name Enter the first name, middle initial, and last name as it – Participant’s appears on the IL Medicaid identification card. Sex Indicate the sex of the Participant. – Age Enter the age of the Participant at the time service (is to be) was rendered. – Date of Birth Enter the month, date, and year of the birth. Use two-digit – Participant’s numbers, e.g., 01/04/64. Section II: Provider Information Medicaid # Enter the Medicaid provider number. – hospital’s Illinois Hospital Name Enter the name of the hospital that (will render) rendered the treatment. – Physician IL Medicaid # Enter the Illinois Medicaid provider number. – physician’s Physician Name Enter the first name, middle initial, and last name of the attending – (Surgeon) physician. Section III: Request Information Request Date Record the date of the request. – Request Method Indicate whether request submitted by fax, mail or telephone. – Requested By Indicate whether the physician or hospital made the request. – Enter the name of the individual requesting the review. Requestor Name – Requestor Telephone # Enter the telephone number of the requestor including area code. – Section IV: Reconsideration Information Date of Denial Notification Enter the date medical necessity denial letter was issued. – Date of Admission Enter the date the patient was admitted to the hospital. – Rationale for Request Enter the medical basis/rationale for disagreement. – Additional information submitted Indicate whether additional information is submitted – with the request.
INSTRUCTIONS Section I: Participant Information Recipient Identification # – Enter the Participant’s number that appears on the IL Medicaid identification card. Participant Name – Enter the Participant’s first name, middle initial, and last name as it appears on the IL Medicaid identification card. Sex – Indicate the sex of the Participant. Age – Enter the age of the Participant at the time service (is to be) was rendered. Date of Birth – Enter the month, date, and year of the Participant’s birth. Use two-digit numbers, e.g., 01/04/64. Section II: Provider Information Medicaid # – Enter the hospital’s Illinois Medicaid provider number. Hospital Name – Enter the name of the hospital that (will render) rendered the treatment. Physician IL Medicaid # – Enter the physician’s Illinois Medicaid provider number. Physician Name – Enter the first name, middle initial, and last name of the attending (Surgeon) physician. Section III: Request Information Request Date – Record the date of the request. Request Method – Indicate whether request submitted by fax, mail or telephone. Requested By – Indicate whether the physician or hospital made the request. Requestor Name – Enter the name of the individual requesting the review. Requestor Telephone # – Enter the telephone number of the requestor including area code. Section IV: Reconsideration Information Date of Denial Notification – Enter the date medical necessity denial letter was issued. Date of Admission – Enter the date the patient was admitted to the hospital. Rationale for Request – Enter the medical basis/rationale for disagreement. Additional information submitted – Indicate whether additional information is submitted with the request.
Prior%20Auth%20Provider%20Manual%20Rev%201.docx