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Addiction and Recovery Treatment Services (ARTS) Service Authorization Review Form - Extension Reque 2026

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The document is a Service Authorization Review Form for Addiction and Recovery Treatment Services (ARTS), specifically for extension requests related to various ASAM levels of care. It outlines the necessary information required from both members and providers, including member details, service authorization numbers, requested levels of care, medication lists, assessment dimensions, and supporting clinical documentation. The form aims to facilitate the extension of treatment services for individuals undergoing addiction recovery.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the member information, including the Member Name, DOB, and Member ID. If applicable, provide the enrollment date.
Next, fill in the provider information such as Provider Group/Clinic, Clinical Contact, and address details. Ensure you include the Provider ID/NPI.
In the ICD-10 Diagnosis Code section, enter all relevant diagnosis codes for the member.
Complete the Service Authorization section by providing the existing service authorization number and requested end date for the extension.
Select the ASAM Level of Care requested and indicate the number of units required for each service type.
Document medications prescribed by listing their names, types/dosages/frequencies, patient responses, and prescribers.
Fill out assessment dimensions by summarizing member needs/strengths for each dimension and attaching any necessary clinical notes.
Finally, complete documentation regarding treatment progress, revised goals, discharge plans, and sign off with your name and credentials before submitting.

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Versions	Form popularity	Fillable & printable
2022	4.8 Satisfied (55 Votes)
2018	4.3 Satisfied (58 Votes)

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How can I create an electronic signature in my arts service authorization request on Android?

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How do you get Addiction and Recovery Treatment Services (ARTS) Service Authorization Review Form - Extension Reque for my state?

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What is the phone number for Virginia Medicaid prior authorization?

What does VA Medicaid cover?

Medicaid covers a variety of inpatient and outpatient medical services. Benefits include behavioral health services, addiction and recovery treatment, dental services and prescription medicines.

What is the phone number for Virginia Medicaid prior authorization?

For assistance with billing, claims, member eligibility, memos and other regulations, call the Virginia Medicaid Provider Helpline at the toll-free (800-552-8627) or in-state (804-786-6273) phone numbers. For Providers - Department of Medical Assistance Services - Virginia.gov virginia.gov for-providers virginia.gov for-providers

Does VA Medicaid require prior authorization?

Phone: Call 844-284-0146. Prior authorization is not required for emergency or urgent care. Out-of-network physicians, facilities and other health care providers must request prior authorization for all procedures and services, excluding emergent or urgent care. Prior Authorization Requirements for Virginia Medicaid - UHCprovider.com uhcprovider.com docs public commplan uhcprovider.com docs public commplan

How do I get approved for Medicaid in VA?

You can apply for Virginia Medicaid in one of three ways and all are efficient: Apply online at commonhelp.virginia.gov. Apply by calling the Cover Virginia Call Center at 1-833-5CALLVA (1-833-522-5582) (TDD: 1-888-221-1590), Monday Friday, 8 a.m. to 7 p.m., and Saturday, 9 a.m. to noon.

What is the monthly income limit for Medicaid in Virginia 2023?

Income Asset Limits for Eligibility 2023 Virginia Medicaid Long-Term Care Eligibility for SeniorsType of MedicaidSingleMarried (one spouse applying)Medicaid Waivers / Home and Community Based Services$2,742 / month$2,742 / month for applicantRegular Medicaid / Aged Blind and Disabled$972 / month$1,315 / month2 more rows Jun 20, 2023

Addiction and Recovery Treatment Services (ARTS) Service Authorization Review Form - Extension Reque 2026

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How to use or fill out Addiction and Recovery Treatment Services (ARTS) Service Authorization Review Form - Extension Request with our platform

See more Addiction and Recovery Treatment Services (ARTS) Service Authorization Review Form - Extension Reque versions

Complete this form in 5 minutes or less

Got questions?

How can I create an electronic signature in my arts service authorization request on Android?

How do you get Addiction and Recovery Treatment Services (ARTS) Service Authorization Review Form - Extension Reque for my state?

What is the phone number for Virginia Medicaid prior authorization?

What does VA Medicaid cover?

What is the phone number for Virginia Medicaid prior authorization?

People also ask

Does VA Medicaid require prior authorization?

How do I get approved for Medicaid in VA?

What is the monthly income limit for Medicaid in Virginia 2023?

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