Submit fax request for Service Authorization to: 1-877–OKBYFAX (877-652-9329). Requests may be submitted up to 30 days prior to scheduled procedures/services, provided the Member is eligible. Recert: Enter previous SRV AUTH#. Change or Cancel: enter SRV AUTH# to be changed or canceled. Initial Recertification Change Cancel SRV AUTH # Date of request: (mm/dd/yyyy) Review Type: (Please check one if applicable) / / Retrospective Prepayment Review (Date notified of eligibility / / Retroactive MCO disenrollment Member Last Name: Member First Name: a. Member Medicaid ID Number (12 digit Number): b. Eligibility (Mandatory) Medicaid FFS Medicaid Expansion Date of Birth: (mm/dd/yyyy) Sex: NPI/API Submitting Provider Name: / / Male Medicaid ID Number: Female c. 9 digit Zip Code (Mandatory) Treatment Admission Date: Admission Status: NPI/API Facility Name: Setting: (mm/dd/yyyy) Urgent Inpatient Elective Medicaid ID Number: / / 9 digit Zip Code (Mandatory) Primary Diagnosis Code/Description: (enter up to 5) 1. 2. 3. 16. Number of Days Attending Physician SRV AUTH Service Type: Requested: Medicaid ID Number/NPI: 0200 Intensive Rehabilitation Severity of Illness (Clinical indicators of illness including abnormal findings): Intensity of Services (Proposed/Actual monitoring and therapeutic services): Additional Comments (See Instructions): Contact Name: Contact Telephone Number: Contact Fax Number:
Submit fax request for Service Authorization to: 1-877–OKBYFAX (877-652-9329). Requests may be submitted up to 30 days prior to scheduled procedures/services, provided the Member is eligible. Initial Recertification Change Cancel Recert: Enter previous SRV AUTH#. Change or Cancel: enter SRV AUTH# to be changed or canceled. SRV AUTH # Date of request: (mm/dd/yyyy) / / Review Type: (Please check one if applicable) Retrospective Prepayment Review (Date notified of eligibility / / Retroactive MCO disenrollment a. Member Medicaid ID Number (12 digit Number): b. Eligibility (Mandatory) Medicaid FFS Medicaid Expansion Member Last Name: Member First Name: Date of Birth: (mm/dd/yyyy) / / Sex: Male Female NPI/API Submitting Provider Name: Medicaid ID Number: c. 9 digit Zip Code (Mandatory) NPI/API Facility Name: Medicaid ID Number: 9 digit Zip Code (Mandatory) Treatment Setting: Inpatient Admission Date: (mm/dd/yyyy) / / Admission Status: Urgent Elective Primary Diagnosis Code/Description: (enter up to 5) 1. 2. 3. 16. Number of Days Requested: Attending Physician Medicaid ID Number/NPI: SRV AUTH Service Type: 0200 Intensive Rehabilitation Severity of Illness (Clinical indicators of illness including abnormal findings): Intensity of Services (Proposed/Actual monitoring and therapeutic services): Additional Comments (See Instructions): Contact Name: Contact Telephone Number: Contact Fax Number:
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