Prior Authorization Forms for Medicaid and Medicare Advantage Plans

ARTS DMAS Provider Attestation Form

ARTS Peers Registration Request

ARTS Peers Service Authorization Guidelines

ARTS Service Authorization Review - Extensions

ARTS Service Authorization Review - Initial Request

ARTS Substance Use Case Management Registration

Advanced Imaging Codes

Authorization Request for Advanced Imaging Services

LTSS Agency Directed Services Request Form CCC Plus Waiver (all ages)

LTSS Agency Directed Services Request Form EPSDT (under 21 without waiver)

Continuous Glucose Monitors (CGM) (PREFERRED: Dexcom | FreeStyle Libre 1 | FreeStyle Libre 2 | FreeStyle Libre 3) (Non-Preferred: Eversense | Gaurdian)

LTSS Authorization Request Form

Part D Redetermination Request (Appeal) Form

Pre-Authorization Reconsideration Form

Request a standard decision for Medicare Part C (medical items or services)

Behavioral Health Discharge Summary for Medicare and Medicaid

Behavioral Health Inpatient Authorization Request for Medicare and Medicaid

Behavioral Health Outpatient Authorization Request for Medicare and Medicaid

Electroconvulsive Therapy (ECT) Authorization Request for Medicare and Medicaid

Transcranial Magnetic Stimulation (rTMS) Authorization Request Form

LTSS Consumer Directed Services Request Form CCC Plus Waiver (all ages)

LTSS Consumer Directed Services Request Form EPSDT (Under 21 NO WAIVER)

DME Authorization for Medicare and Medicaid

Durable Medical Equipment (DME) Request Form for Optima Community Care (formerly Virginia Premier)

Authorization Request for Nutritional Therapy and Enteral Supplies - Government Programs

Authorization Request for Outpatient Intravenous Therapy - Government Programs

Home Health Authorization - Government Programs

Authorization Request for Currently Hospitalized Members (Inpatient or Observation)

Authorization Request for Future Inpatient Services

Authorization Request for Future Outpatient Services

Authorization Request for Inpatient Skilled Nursing Facility Services

Authorization Request for Post-Acute Inpatient Rehabilitation or Long-Term Acute Care

Authorization Request Outpatient Physical-Occupational-Speech Therapies

Addiction And Recovery Treatment Services (ARTS) And Mental Health Services (MHS) Registration Form

Applied Behavior Analysis CONTINUED STAY Service Authorization Request Form

Applied Behavior Analysis INITIAL Service Authorization Request Form

Assertive Community Treatment Continued Stay Service Authorization Request Form

Assertive Community Treatment Initial Service Authorization Request Form

Community Stabilization Continued Stay Service Authorization Request Form - February 14 2023

Community Stabilization Initial Service Authorization Request Form - February 14 2023

Community Stabilization Referral Form

Enhanced Services Individual Service Plan Template

Functional Family Therapy CONTINUED STAY Service Authorization Request Form

Functional Family Therapy Initial Service Authorization Request Form

Intensive In-Home Initial Service Authorization Request Form

Mental Health Intensive Outpatient And Partial Hospitalization Program Continued Stay Service Auth

Mental Health Intensive Outpatient And Partial Hospitalization Program Initial Service Auth Request

Mental Health Skill-Building Initial Service Authorization Request Form

Multisystemic Therapy Continued Stay Service Authorization Request Form

Multisystemic Therapy Initial Service Authorization Request Form

Psychosocial Rehabilitation Initial Service Authorization Request Form

Residential Crisis Stabilization Unit CONTINUED STAY Service Authorization Request Form

Service Authorization Form CMHRS Continued Stay Service Authorization Request Form

Therapeutic Day Treatment Initial Service Authorization Request Form

OB/Prenatal Certification Form

LTSS Private Duty Nursing Authorization Request Form

Authorization for Urgent Services

Chemotherapy Administration Medical Policy 316

Policy for Oncology use for WBC Growth Factor