The Prior Authorization Program is designed to ensure that only medically necessary services are provided in a cost-effective manner. The program also is responsible for ensuring that medically necessary services are not denied to recipients.

Click here to view 10/7/09 ALERT regarding additional information for PA reconsiderations.

• Revised Wheelchair/Seating Evaluation Form 384 - Cathy Carver, Qualis Health, PowerPoint presentation - 3/21/12
• Webinar - Revised Wheelchair/Seating/Evaluation Form 384 - Cathy Carver, Qualis Health, PowerPoint presentation playback - 3/23/12
• Survey - Revised Wheelchair/Seating/Evaluation Form 384 Webinars - Participants in either 3/21/12 or 3/23/12 webinars are encouraged to fill out this survey
• Provider Manual - Chapter 4
• Radiology Management Program
• Hospitals Participating in PT Evaluations
• Update - Delivery Ticket

Forms

• Prior Review and Authorization Request - Fillable Form 342 - A completed form is required - Updated 12/7/11
• Wheelchair/Seating Evaluation Form 384 - Required attachment for Form 342 - Effective 4/1/12
• Wheelchair/Seating Evaluation Form 384 - Required attachment for Form 342 (may not be submitted after 4/30/12)
• Prior Authorization Change Request Form 471 -
  NOT to be used for Pharmacy PAs - Updated 12/8/11
• Dental Prior Approval - Form 343 - Updated 2/10/10
• Cochlear Implant Request Form
• Oxygen Therapy Request Form 360 - Updated 2/12
• Pharmacy PA Request Forms - Includes Criteria
• Augmentative Communication Device Evaluation Report Form - Form 480 - Fillable Form updated 3/29/11
• Instructions for Form 480 - Instructions and more information related to the ACD Evaluation Report Form