Forms

The best way to ensure that your Service Authorization submission is quickly processed is to include all the documentation required for the request to be reviewed. If necessary documentation is not included or completed inaccurately, your submission may be delayed or a Reviewer may have to contact you and request the additional information, prolonging the review time.

In addition to any required documentation below, including other relevant information such as clinical documentation, treatment plans (if applicable), nursing notes, or specialty physician office visit notes may help accelerate the review process.

Don’t see the form you need here? Please visit the Department of Medical Assistance Services’ Forms Library to search for what you need.

Service Type Code and/or Request Type Form(s) or Document(s) Required in Submission
 

0050 Outpatient Psych

 

 H2033 and H0036  

1.      Comprehensive Needs Assessment (CNA).

2.      Individualized Service Plan (ISP).
Continuity of Care Request  

Evidence of previous Service Authorization approval.

 
H2018, S9482  

Safety Plan, Care/Discharge Planning.

*based on Provider and their EHR

 
Assertive Community Treatment, Mental Health Intensive Outpatient (MH-IOP), and Mental Health Partial Hospitalization (MH-PHP) Comprehensive Needs Assessment (CNA).
0051 ARTS Continuity of Care  

Evidence of previous Service Authorization approval.

 
0052 Baby Care Infant  

1.      DMAS -50 (I).

2.      Evidence of previous Service Authorization approval.

3.      Physician Order.

 
Maternal  

1.      DMAS-50 (M).

2.      Evidence of previous Service Authorization approval.

3.      Physician Order.

 
0090 EPSDT PDN S9123, S9124, G0493, G0494  

1.      Home Health Certification Plan of Care (CMS-485).

2.      Private Duty Nursing SA Form (DMAS-62).

*For FAQs related to this form, click here.

3.      Individualized Education Program (IEP).
0091 EPSDT Personal Care/Attendant Care All codes and request types.

1.      Medical Necessity Assessment and Personal Care (DMAS-7 and DMAS-7A).

2.      Community-Based Care Member Assessment Form (DMAS-99).
0092 Assistive Tech All codes and request types.  

Evidence of previous Service Authorization approval.

 
0093 EPSDT Inpatient Psych All codes and request types. Evidence of previous Service Authorization approval.
0094 IACCT and ABA IACCT, 90089  

Child and Adolescent Needs and Strengths Assessment (CANS).

 
ABA, 97153-97158, 0373T  

1.      Comprehensive Needs Assessment (CNA).

2.      Individualized Service Plan (ISP).

3.      Evidence of previous Service Authorization approval.

 
0098 EPSDT PDN S9123, S9124, G0493, G0494  

4.      Home Health Certification Plan of Care (CMS-485).

5.      Private Duty Nursing SA Form (DMAS-62).

*For FAQs related to this form, click here.

6.      Individualized Education Program (IEP).

 
0100 Durable Medical Equipment All codes and request types.  

1.      Evidence of previous Service Authorization approval.

2.      Certificate of Medical Necessity (DMAS-352).

 
K0001  

Include an Invoice in the request, including MSRP if discounts were provided.

 
0200 Intensive Rehab All codes and request types.  

1.      Plan of Care (POC).

2.      Evidence of previous Service Authorization approval.

 
 

0204 Outpatient Rehab

 All codes and request types.  

1.      Plan of Care (POC).

2.      Evidence of previous Service Authorization approval.

3.      Physician Order.

4.      Revenue Codes for Outpatient Rehab.

 
 

0300 Stem Cell and Organ Transplant

 

 All codes and request types.

1.      Plan of Care (POC).

2.      Physician Order.
0302 Surgical Procedures, Genetics Lab, and Molecular Pathology All codes and request types.

1.      Evidence of previous Service Authorization approval.

2.      Physician Order.
0303 Prosthetics All codes and request types.  

1.      Evidence of previous Service Authorization approval.

2.      Certificate of Medical Necessity (DMAS-352).

3.      Invoice.

*Including MSRP, if discounts were provided.

4.      Physician Order.

 
0304 MDSM All codes and request types.  

1.      Evidence of previous Service Authorization approval.

2.      Certificate of Medical Necessity (DMAS-352).

3.      Invoice.

*Including MSRP, if discounts were provided.

4.      Physician Order.

 
0400 Inpatient Admission All codes and request types.  

Evidence of previous Service Authorization approval.

 
0401 Inpatient Psych All codes and request types.  

Evidence of previous Service Authorization approval.

 
0500 Home Health All codes and request types.  

1.      Evidence of previous Service Authorization approval.

2.      Home Health Certification Plan of Care (DMAS-485).

3.      Plan of Care (POC).

4.      Physician Order.

5.      Revenue Codes for Home Health Services.

 
0650 CMHRS Intensive In-Home Services (IIH), Therapeutic Day Treatment (TDT), and Mental Health Skill-Building Services (MHSS) Comprehensive Needs Assessment (CNA).
0700 Treatment Foster Care – CM All codes and request types.  

1.      Family Assessment and Planning Team (FAPT)

*based on Provider and their EHR. 

2.      Individualized Service Plan (ISP).

3.      Child and Adolescent Needs and Strengths Assessment (CANS).

 
0750 Psychiatric Residential Treatment Facility (CSA) All codes and request types.  

1.      Individualized Plan of Care (IPOC).

*based on Provider and their EHR. 

2.      Comprehensive Individual Plan of Care (CIPOC).

*based on Provider and their EHR. 

3.      Certificate of Need (CON), Retro PRTF.

4.      CSA Reimbursement Rate Certification (DMAS-600).

 
0751 Psychiatric Residential Treatment Facility (Non-CSA) All codes and request types.  

1.      Individualized Plan of Care (IPOC).

*based on Provider and their EHR. 

2.      Comprehensive Individual Plan of Care (CIPOC).

*based on Provider and their EHR. 

3.      Certificate of Need (CON), Retro PRTF.

 
0753 Therapeutic Group Home All codes and request types.  

1.      Individualized Plan of Care (IPOC).

*based on Provider and their EHR. 

2.      Comprehensive Individual Plan of Care (CIPOC).

*based on Provider and their EHR. 

3.      Certificate of Need (CON), Retro TGH.

4.      CSA Reimbursement Rate Certification (DMAS-600).

 
0900 EDCD S9125 Home Health Certification Plan of Care (CMS-485).
0960 Tech Waiver S9125 Home Health Certification Plan of Care (CMS-485).
1020 Specialized Care Long Stay Hospital All codes and request types. Specialized Care/Long Stay Acute Care Hospitals Information Sheet (DMAS-SPEC-100).
Birth Injury Fund All codes and request types. Insurance Verification Documentation.