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LA-PAF-0658 - Outpatient Prior Authorization Form Outpatient Prior Authorization Form

LA-PAF-0658 - Outpatient Prior Authorization Form Outpatient Prior Authorization Form-2026

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4.9 out of 5

30 votes

The document is an Outpatient Prior Authorization Form used to request additional units of medical services. It outlines the necessary information required from both the member and requesting provider, including Medicaid ID, procedure codes, and diagnosis codes. The form specifies different fax numbers for standard and transplant requests, emphasizes the importance of completing all required fields, and includes a disclaimer about authorization not guaranteeing payment. Confidentiality notice is also provided.

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Click ‘Get Form’ to open the LA-PAF-0658 in our editor.
Begin by filling out the MEMBER INFORMATION section. Enter the Medicaid/Member ID, Date of Birth, and Last Name, First. Ensure all required fields marked with an asterisk (*) are completed.
Proceed to the REQUESTING PROVIDER INFORMATION section. Input the Requesting NPI, TIN, Provider Name, Contact Name, Phone, and Fax. Double-check for accuracy.
In the SERVICING PROVIDER / FACILITY INFORMATION section, if applicable, select 'Same as Requesting Provider' or fill in the Servicing NPI and TIN along with other details.
Complete the AUTHORIZATION REQUEST section by entering the Primary Procedure Code and any Additional Procedure Codes as necessary. Select the OUTPATIENT SERVICE TYPE from the provided options.
Fill in dates for Start Date or Admission Date and End Date or Discharge Date. Include Diagnosis Code and Total Units/Visits/Days.
Answer questions regarding Discharge Needs and Chronic Needs Case as applicable. Remember that all required fields must be filled in to avoid rejection.

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Versions	Form popularity	Fillable & printable
2022	4.9 Satisfied (30 Votes)
2016	4.1 Satisfied (55 Votes)
2015	4 Satisfied (46 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Can I request my own prior authorization?

You can submit a request on your own. Find the appropriate prescription drug or medical procedure authorization form for your situation.

How to obtain prior authorization?

How To Get Prior Authorization: Step-by-Step Guide Step 1: Check client eligibility. Step 2: Determine if a code or service requires Prior Authorization. Step 3: Find and complete forms. Step 4: Submit a PA request. Step 5: Check the status of an authorization.

Does Louisiana Medicaid require prior authorization?

Providers need prior authorization (PA) for some outpatient care and planned hospital admissions. We dont require PA for emergency care. You can find a current list of the services that need PA on the Provider Portal.

Who is responsible for obtaining preauthorization?

Studies show the average cost for prior authorization approval on primary care practices ranged from $2,161 to $3,430 annually per full-time physician. In addition to the impact on physicians, prior authorization requirements have been found to harm patient care.

What is outpatient prior authorization?

Some services, medicines, or items need approval from Health Partners Plans before you can get the service. This approval process is called prior authorization. Prior authorizations are sometimes referred to as preauthorizations or precertifications or preapprovals they mean the same thing.

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