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Click ‘Get Form’ to open the Mental Health Service Prior Authorization Request Form in the editor.
Begin by filling out the MEMBER INFORMATION section. Enter the Member Name, Date of Birth (DOB), and Member ID. If applicable, provide the enrollment date for retroactive enrollment.
Next, complete the PROVIDER INFORMATION section. Input details such as Provider Group/Clinic, Contact Name, Phone, Fax, Street Address, City, State, Zip Code, and Provider ID/NPI.
In the AUTHORIZATION REQUEST section, specify the start date and estimated duration of care. Then list any primary and co-occurring diagnoses in the DIAGNOSIS section.
Follow with MEDICATION details by listing medications along with their dosage and frequency.
Indicate the CA/LOCUS LEVEL OF CARE BASED ON SCORE and select the LEVEL OF CARE REQUESTED from the options provided.
If there is a variance between recommended and requested levels of care, explain this in the designated area and attach supporting documentation.
Complete the REQUESTED CODES section by including codes for services needed along with units/visits and modifiers if applicable.
Finally, ensure to sign off on the form by entering your name (print), signature/credential, and date in the SIGNATURE section before submitting.
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Dont be Fooled by Imitations: .wahealthplanfinder.org is the official health insurance marketplace for Washington state and the only place where you can receive tax credits, cost-sharing reductions, or access to free coverage through Washington Apple Health.
What is the Washington state healthcare number?
Contact Details Organization Type:State Medical Assistance Office Organization Name: Health Care Authority Organization Description: Medicaid program Covered States and Territories: Washington Information: Toll Free: (800) 562-3022 Fax: (360) 586-7498 Web Site: Hours: 7:30 am - 4:30 pm
What is Washington states version of Medicaid called?
In Washington State, Medicaid is called Apple Health. Apple Health provides preventative care, like cancer screenings, treatment for diabetes and high blood pressure, and many other health care services.
What is the phone number for UHC Washington Apple Health?
Call the Health Care Authority at 1-800-562-3022 (TTY: 711). Other members should call Apple Health Customer Service at 1-800-562-3022 to cancel/terminate Medicaid coverage. Hearing or speech impaired members should call TTY: 711.
What counts as income for Washington Healthplanfinder?
Salary, wages, tips and commissions. Self-employment income (minus business expenses) Unemployment compensation. Title II Social Security benefits (including retirement, disability and benefits for survivors)
What is the income limit for Washington. Apple Health?
Adults (19-64)Apple Health eligibility Total number in family (including yourself)Monthly income limit for free coverageAnnual income limit for free coverage 1 $1,780 $21,597 2 $2,433 $29,187 3 $3,065 $36,777 4 $3,697 $44,3672 more rows
What is the phone number for Washington Healthcare Finder?
Washington Healthplanfinder partners with insurance specialists across the state. Find one in your area below! You can also reach out to our Customer Support Center at 1-855-923-4633.
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