Reinstatement eligibility: Fill out & sign online

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Click ‘Get Form’ to open the magnolia prior authorization in the editor.
Begin by filling out the MEMBER INFORMATION section. Enter the Member ID/Medicaid ID, Date of Birth, and Requesting NPI. Ensure all fields marked with an asterisk (*) are completed as they are required.
Next, provide details in the SERVICING PROVIDER / FACILITY INFORMATION section. Fill in the Servicing NPI, Servicing TIN, and contact information for the servicing provider.
In the AUTHORIZATION REQUEST section, input the Primary Procedure Code and any additional procedure codes. Specify start and end dates along with total units/visits/days required.
Complete any additional questions regarding therapy services for school-aged members if applicable. Make sure to check all relevant outpatient service types by marking them with an X.
Review your entries carefully to ensure all required fields are filled out accurately before submitting.

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