Medical Prior Authorization and Physician Forms

Patient Health Guidelines:

• Clinical Guidelines
• Preventive and Immunization Guidelines
• Medical Record Documentation Guidelines
• Utilization Management Clinical Criteria

Physician Forms:

• Autism Treatment Plan
• MCO Shift Care Form
• Self-Audit Overpayment Form
• Personal Designation Form
• CardioMEMS Heart Failure Monitoring System
  • Medical Necessity Form (MNF) for CardioMEMS Heart Failure Monitoring System – MP.PA.103
• Home Accessibility
  • Medical Necessity Form (MNF) for Home Accessibility Durable Medical Equipment
• Home Health
  • Medical Necessity Form (MNF) for Home Health
• Long Term Services and Supports (LTSS) for CHC
  • Medical Necessity Form (MNF) for Long Term Services and Supports for CHC
• Nutritional Products
  • Medical Necessity Form (MNF) for Nutritional Products
• Obstetrical Needs Assessment
  • Instructions
  • Blank form
  • Example of a completed form
• Out-of-Network Service Requests
  • Medical Necessity Form (MNF) for Out-of-Network Requests
• Parenteral Nutrition
  • Medical Necessity Form (MNF) for Parenteral Nutrition
• Provider Consent Form to File a Fair Hearing on Behalf of a Member
• Provider Consent Form to File a Grievance for a Member
• Provider Consent Form to file a Grievance for a UPMC Community HealthChoices participant
• Private Duty Nursing
  • Medical Necessity Form (MNF) for Private Duty Nursing
  • Tip Sheet for Requesting Authorization of Shift Care Services
  • Concurrent Authorization Request Form
  • Agency Request Form to Transfer Shift Care Hours
  • Shift Care Services Additional Hours Form
• Provider Appeal Forms
  • Expedited Provider Appeal Certification Form
  • Provider Dispute/Appeal Cover Sheet
  • Provider Appeal on Behalf of a Member

Physician Certification Form for Child with Special Needs:

In Pennsylvania, children with certain permanent or temporary disabilities are eligible for a special category of Medical Assistance (MA) called PH95.

• Physician Certification Form and Instructions for Child with Special Needs
• Letter Addressed to Physician from Department