DIVISION OF MEDICAL SERVICES A CHMS REQUEST FOR PRIOR

 EMPLOYEES’ COMPENSATION DIVISION LABOUR DEPARTMENT STATEMENT OF
  WORKERS’ COMPENSATION DIVISION WORKER’S AND HEALTH CARE
EXECUTIVE OFFICEDIVISION NAME BUREAUDISTRICT OR SECTION NAME PO

STATE OF WISCONSIN DEPARTMENT OF ADMINISTRATION DIVISION OF ENTERPRISE
CHAMPIONNAT PROVINCIAL – SOCCER DIVISION 1 DOCUMENT
CITY OF TULSA PURCHASING DIVISION 175

DMS CHMS Request for Prior Authorization


DIVISION OF MEDICAL SERVICES

A. CHMS REQUEST FOR PRIOR AUTHORIZATION

PROVIDER NAME: (1)

ADDRESS: (2)

PROVIDER PHONE AND FAX #: (3)

PROVIDER ID NUMBER/TAXONOMY CODE: (4)

BENEFICIARY’S LAST NAME: (5)

FIRST: (6)

M.I.: (7)

BENEFICIARY’S MEDICAID ID #: (8)

DATE OF BIRTH: (9)

SEX: (10)

MALE FEMALE

PARENT/GUARDIAN NAME: (11)

BENEFICIARY’S PHONE NUMBER HOME/MESSAGE: (12)

MAILING ADDRESS (Street, P.O. Box, City, State, and Zip Code): (13)

COUNTY RESIDENCE: (14)

PCP NAME: (15)

PCP PROVIDER ID #/TAXONOMY CODE: (16)

PRIMARY DIAGNOSIS: (17)

SECONDARY DIAGNOSIS: (18)

OTHER DIAGNOSIS: (19)


B. NUMBER OF

PROCEDURE CODES DATE OF SERVICE REQUESTED MONTHS

REQUESTED (20) TO BEGIN (21) UNITS/MONTHS (22) REQUESTED (23)



























































































BRIEF MEDICAL SUMMARY: (24)







ATTACH MEDICAL RECORDS TO SUBSTANTIATE MEDICAL NECESSITY


Provider’s Signature: (25) __________________________________________ Date: (26) __________________________________


Please retain a copy of this form in your files. Send completed form to:


Arkansas Foundation for Medical Care, Inc.

P.O. Box 180001

Fort Smith, AR 72918

Fax # (479) 649-0776

Instructions for Completion of CHMS Request for Prior Authorization Form

Section A – To be completed by the provider requesting prior authorization.

Item 1 – Provider Name: Write the name of the Medicaid provider requesting prior authorization.

Item 2 – List the mailing address of the Medicaid provider requesting prior authorization. Include the nine-digit zip code number.

Item 3 – List the area code, telephone number, and fax number of the Medicaid provider requesting prior authorization.

Item 4 – List the provider identification number and taxonomy code of the Medicaid provider requesting prior authorization.

Item 5 – Beneficiary’s Last Name: Enter the beneficiary’s last name.

Item 6 – First Name: Enter the beneficiary’s first name.

Item 7 – Middle Initial: Enter the beneficiary’s middle initial.

Item 8 – Enter the beneficiary’s ten (10) digit Medicaid ID number.

Item 9 – Enter the beneficiary’s month, day and year of birth. (MM/DD/YYYY).

Item 10 – Check (M) for Male – (F) for Female.

Item 11 – Enter the last name, first name and middle initial of the parent or guardian. Circle whether parent or guardian.

Item 12 – Enter the area code, home telephone number, if available, or a message telephone number. Circle whether a home or message number.

Item 13 – Enter beneficiary’s mailing address. Include the nine-digit zip code.

Item 14 – Enter the county in which the beneficiary resides.

Item 15 – Enter the name of the beneficiary’s Primary Care Physician. If the beneficiary is exempt from PCP requirement, enter the name of the attending physician.

Item 16 – Enter the provider identification number and taxonomy code of the Primary Care Physician.

Item 17 – Enter the ICD Diagnosis Code and nomenclature representing the patient’s primary condition or symptom requiring or contributing to the need for the prescribed procedure codes.

Item 18 – Enter the ICD Diagnosis Code and nomenclature representing the patient’s secondary condition or symptom requiring or contributing to the need for the prescribed procedure codes.

Item 19 – Enter a tertiary ICD Diagnosis Code, if applicable.

Section B:

Item 20 – Enter the CHMS treatment procedure code(s) requested. Refer to Section II of this manual for appropriate codes.

Item 21 – Enter the requested date of service to begin for each procedure code.

Item 22 – Enter the number of units requested for each procedure code.

Item 23 – Enter the number of months requested for each procedure code.

Item 24 – Write a brief medical summary. NOTE: Attach medical records to substantiate medical necessity for each procedure code requested.

Item 25 – Request must be signed by the provider requesting prior authorization or by the provider’s authorized representative.

Item 26 – Date of the signature by the provider requesting prior authorization.

DMS-102 (12-15-14)


DEPARTMENT OF CONSUMER AND BUSINESS SERVICES DIVISION OF
DEPARTMENT OF CONSUMER AND BUSINESS SERVICES INSURANCE DIVISION
GOBIERNO DE CHILE DIRECCION DEL TRABAJO DIVISION DE


Tags: division of, request, services, prior, division, medical