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Form la paf 0658-2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the member information. Fill in the Member ID/Medicaid ID and Date of Birth in the required fields marked with an asterisk (*).
- Next, provide the requesting provider information. Enter the Requesting NPI, TIN, Contact Name, and Phone number.
- For servicing provider/facility information, if applicable, check 'Same as Requesting Provider' or fill in the Servicing NPI and TIN along with contact details.
- In the authorization request section, complete all required fields including Primary Procedure Code, Diagnosis Code, and Total Units/Visits/Days.
- Select the Outpatient Service Type by entering the corresponding service type number from the provided list.
- Ensure all required fields are filled out completely to avoid rejection. Attach any necessary supporting clinical information before submission.
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Does Medicare Part B require prior authorization?
Some Part B drugs require prior approval before they can be administered. This is called precertification or prior authorization. This helps us review a drug to ensure its safe and appropriate for your patient. Our medical precertification lists feature the latest information, including Part B drugs.
How to check balance on Louisiana Healthcare Connections card?
To check your balance, log in to your secure member portal account.
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