Western Oregon Advanced Health, LLC. P.O. Box 1096
Coos Bay, OR 97420
Instructions to Complete Ancillary Service Authorization Request
For Physical Therapy, Speech Therapy, Occupational Therapy
Provider is responsible for submitting all information in the top portion of the “Ancillary Service Authorization Request” form along with required documentation.Initial therapy evaluations do not require prior authorization, unless provided by an out-of-area provider in which a referral is required.
Required Documentation:
♦ MD’s current prescription or signed order ♦ PT/ST/OT Evaluation
♦ PCP note, Specialist Note, Other diagnostic testing results; all of these items are optional
Fax completed form and documentation to WOAH’s Medical Management Department at (541) 269-7147.
If you have questions regarding this form or other related questions, please contact WOAH’s Medical Management Department at (541) 269-7400.
To complete form, please follow these instructions:
Requesting Provider: Enter the name of the Therapy Provider requesting authorization
Phone #: Enter the office phone number of the requesting Therapy Provider
Fax #: Enter the office fax number of the requesting Therapy Provider
Member Name: Enter the full name of the OHP Member, including middle initial if known.
DOCS ID #: (Required field) Enter the OHP ID number for the Member
DOB: Enter Member’s date of birth
Prescribing MD: Enter the name of the physician who prescribed therapy
PCP: Enter the name of the Member’s Primary Care Physician
Requested Date of Service: Enter the date duration needed to complete the therapy
ICD-10 Code(s): (Required field > 10-01-2015) Enter the ICD-10 codes for the
diagnoses that relate to the requested services. Diagnosis must be coded to the highest level of specificity.
Item/Services Requested: Enter the description of the therapy or modality being requested
Codes and applicable modifiers: See below
- Outpatient/Non-Hospital based: Enter the CPT codes for each therapy and/or modality being requested
- Outpatient/Hospital based: Enter the Revenue Code and correlating CPT code for each individual therapy and/or modality being requested.
- Skilled Nursing Facility: Enter the Revenue Code and correlating CPT code for each individual therapy and/or modality being requested.
- Home Health: Please use the “Home Health Authorization Request” form
Quantity Requested: Enter the quantity of each type of therapy being requested
Documents attached: Mark the appropriate box to indicate if the required
documentation is attached. (*Required documentation = See above)
If “Yes”, please specify: Indicate what documentation is being submitted with the request form.
Comments: Add any additional information that is pertinent to the request.
Signature of Requesting Provider: The Non-Physician Provider who is requesting therapy services must sign the authorization request.
Date: Enter the date the Non-Physician Provider signed the Referral Request.
Instructions to Complete Ancillary Service Authorization Request
For Durable Medical Equipment (DME) or Oral Enteral Supplements
Requesting Provider is responsible to submitting all information in the top area of the form.This form is used for submitting prior authorization requests only. For Referral/PA physician services use the “Physician Referral/Prior Authorization Request” form.
Required Documentation:
DME:
♦ DME requiring Certificates of Medical Necessity (CMN’s) can be submitted with the
dispensing RX. The request will be pended waiting the receipt of CMN or other information as requested.
Oral Enteral Supplements:
♦ Criteria letter must be submitted with request as well as the prescription. Units submitted must be in calories, not cans per day.
Disclaimer: Approval does not assure payment, which also depends on patient eligibility on date of service, contract terms, and compliance with rules, regulations and policies of WOAH and/or OHA as applicable.
Fax completed form and documentation to WOAH’s Medical Management Department at (541) 269-7147.
If you have questions regarding this form or other related questions, please contact WOAH’s Medical Management Department at (541) 269-7400.
To complete form, please follow these instructions:
Requesting Provider: Enter the name of the provider that is submitting the request
Phone #: Enter the phone of the requesting provider
Fax #: Enter the fax number of the requesting provider
Member Name: Enter the full name of the OHP Member, including middle initial, if known
DOCS ID#: (Required field) Enter the Member’s OHP ID#
DOB: (Required field) Enter the Member’s date of birth
Prescribing MD: Enter the physician who prescribed the equipment
PCP: Enter the PCP for the OHP member, if known. Leave blank if unknown.
Requested Dates: Enter the requested dates to provide equipment or services.
ICD-10 Code(s): (Required field > 10-01-2015) Enter the ICD-10 codes for the
diagnoses that relate to the requested services. Diagnosis must be coded to the highest level of specificity.
Codes and applicable modifiers: Enter the valid HCPCS code for the item requested and modifier. Modifier for contracted items as in contracts or for
Purchase Items = NU, Rental Items = RR
Quantity Requested: Enter quantity of item or service requested.
Unit of Measure: Enter units in accordance as utilized in billing process. (e.g. per box, each, 100 calories or per pair)
Documents attached: Mark the appropriate box to indicate if the required
documentation is attached. (**Required documentation = See above)
If “Yes”, please specify: Indicate what documentation is being submitted with the request form
Other information: Enter any comments or in the case of non-specific HCPCS codes list the RETAIL PRICE for the item. A description of the item must accompany these requests and in certain items the suppliers invoice may be requested.
Signature of Requesting Provider: The person filling out the request must sign the form.
Western Oregon Advanced Health, LLC. P.O. Box 1096, Coos Bay, OR 97420 Voice: 541-269-7400 • 800-264-0014 Fax: 541-269-7147 • TTY: 877-769-7400
** PLEASE NOTE: INCOMPLETE FORMS WILL DELAY THE AUTHORIZATION PROCESS **
Member’s primary health insurance: WOAH OHP Dual Eligible - has Medicare and WOAH OHP Member Name: __________________________________ Plan ID #: __________________ DOB: ___/___/___
Requesting Provider: ______________________________ Phone #: ___________________ Fax #: __________________ Prescribing MD: __________________________________ PCP: ________________________________________
Requested Dates: ____/____/____ to ____/____/____ ICD-10 Code: ________________________ (Required: > 10-01-2015) Item/Service Requested Codes and applicable
modifiers Quantity Requested Unit of Measure (UOM) For Internal use Only
Units requested must be in accordance with standard unit of measure (UOM) utilized for billing purposes.
Documents Attached?: Yes No List Documents: ________________________________________________________ Other Information: _________________________________________________________________________________________ _________________________________________________________________________________________________________ Person Completing Form: ___________________________________________________
Signature of Requesting Provider:_____________________________________________ Date ____/____/____
Disclaimer: Prior Authorization does not assure payment, which also depends on patient eligibility on date of service, contract terms, and compliance with rules, regulations and policies of DMAP, Medicare and WOAH as applicable.
Ancillary Service Authorization Request
Authorization #: _______________________________________
• For questions call: 541-269-7400 • Fax Completed Form and Records to 541-269-7147•
For Internal Use Only: Notes: ____________________________________________________________________________ _______________________________________________________________________________________________________ Contracted Provider: Yes No
Approved as requested Approved dates: ____/____/____ to ____/____/____
Modified Request: _______________________________________________________________________________ ________________________________________________________________________________________________
MM Staff Signature:___________________________________
Set Unit Limit: Yes No Faxed via: System: ______ Manual: ______
Unit Count: ______________________________ Date: _____/_____/_____ Initials: _____________
Denial Reason __________________________________________________________________________________ Medical Directors Signature (For Denied Services): _______________________________________________________ D PII MC Date: _____/_____/_____ NOA Date: ______/______/______ Initials: __________