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Home > Provider > Prior Authorization (PA) - Provider Instruction Sheets and Prior Authorization Forms

Prior Authorization (PA) - Provider Instruction Sheets and Prior Authorization Forms

Provider Instruction Sheets
 

Prior Authorization Forms
 
 
General Information Word PDF
PA Process Information Sheet (.doc) (.pdf)
Dental Services
Full/Partial Dentures (.doc) (.pdf)
Procedures (.doc) (.pdf)
Orthodontic Procedures (.doc) (.pdf)
Dental Mailing Information (.doc) (.pdf)
Prevident information (July 21, 2009) (.doc) (.pdf)
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Durable Medical Equipment (DME)
General Instructions for DME (.doc) (.pdf)
DME Replacement Part Letter (.doc) (.pdf)
DME Replacement Part Document (.doc) (.pdf)
Apnea Monitor (.doc) (.pdf)
Augmentative Communication Device/System (.doc) (.pdf)
Blood Glucose Monitor for Home Use (.doc) (.pdf)
Bone Growth Stimulator (.doc) (.pdf)
Cochlear Implant Supplies/Repairs (.doc) (.pdf)
CPAP and BiPAP (.doc) (.pdf)
Home Traction (.doc) (.pdf)
Hospital Beds (.doc) (.pdf)
Intermittent Positive Pressure Breathing Equipment (.doc) (.pdf)
Infusion Pump    
    External for Diabetes (.doc) (.pdf)
    External (.doc) (.pdf)
    Implantable (.doc) (.pdf)
Negative Pressure wound Therapy (.doc) (.pdf)
Nutrition Therapy (Enteral and Parenteral) (.doc) (.pdf)
Orthotic Devices (.doc) (.pdf)
Oxygen (.doc) (.pdf)
Pneumatic Compression Devices (.doc) (.pdf)
Power Operated Vehicles (.doc) (.pdf)
Seasonal Affective Disorder (SAD) Lamps (.doc) (.pdf)
Seat Lift Mechanisms (.doc) (.pdf)
Wheelchairs    
    Manual (.doc) (.pdf)
    Power (.doc) (.pdf)
    Specialty (.doc) (.pdf)
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Early Periodic Screening, Diagnosis and Treatment (EPSDT) Option
Optional Treatment (.doc) (.pdf)
Hearing Aids and Services
Hearing Aids and Services (.doc) (.pdf)
In-State Services
Abortion Services (.doc) (.pdf)
Breast Reconstruction (.doc) (.pdf)
Breast Reduction and Mastopexy (.doc) (.pdf)
Circumcision (.doc) (.pdf)
Cosmetic procedures (.doc) (.pdf)
Eyelid Surgery (.doc) (.pdf)
Gardasil Vaccine (.doc) (.pdf)
Gastric Bypass or Gastroplasty (.doc) (.pdf)
Hyperbaric Oxygen (.doc) (.pdf)
Hysterosalpingograms (.doc) (.pdf)
Removal of Excess Skin and Subcutaneous Tissue of the Abdomen (.doc) (.pdf)
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Instate Sterilization Services
Hysterectomy (.doc) (.pdf)
Tubal Ligation (.doc) (.pdf)
Vasectomy (.doc) (.pdf)
Federal Sterilization Instructions (.doc) (.pdf)
Instate Therapy
Letter to Providers   (.pdf)
Occupational Therapy (.doc) (.pdf)
Physical Therapy (.doc) (.pdf)
J-code/Physician Administered Drugs
Botox (.doc) (.pdf)
Non-Rebatable J-Codes (.doc) (.pdf)
Supprelin LA 10/27/2008 (.doc) (.pdf)
Synvisc/Hyalgan/Orthovisc (.doc) (.pdf)
Tysabri (.doc) (.pdf)
Out of State (OOS) Services
Out of State Schaller Anderson Letter to Providers (.doc) (.pdf)
Out of State Schaller Anderson Instruction Sheet (.doc) (.pdf)
Out of State PA Fax Cover Sheet (.doc) (.pdf)
Cochlear Implant Device (.doc) (.pdf)
Podiatry
Podiatry Letter to Providers (.doc) (.pdf)
Podiatry PA Fax Cover Sheet (.doc) (.pdf)
Bunion Surgery (.doc) (.pdf)
Endoscopic Plantar Fasciotomy (.doc) (.pdf)
Selected Foot Surgery (.doc) (.pdf)
Toe Joint Fusion (.doc) (.pdf)
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Transportation
Transportation Procedures (.doc) (.pdf)
Vision Services
Contact Lenses (.doc) (.pdf)
Eyeglasses (.doc) (.pdf)
Low Vision Aids (.doc) (.pdf)
Medical Eye Care PA Summary (.doc) (.pdf)
Medical Eye Care Benefit (.doc) (.pdf)

Prior Authorization Forms

Prior Authorization Forms
Dental Prior Authorization Forms    
DME Supplies/Equipment Prior Authorization Form (MA-56) (.doc) (.pdf)
Hyaluronic Acid Derivatives (Synvisc, Hyalgan, Euflexxa, Orthovisc) (.doc) (.pdf)
Non-Rebateable J-Codes form (.doc) (.pdf)
Optional Treatment PA form (.doc) (.pdf)
Pharmacy Prior Authorization Forms (Goes to the MaineCare Pharmacy website.)    
Supprelin LA 09/25/08 Prior Authorization Form (.doc) (.pdf)
Tysabri Prior Authorization Form (.doc) (.pdf)

 

Note:If you can not read the above files you can use these links to access Word Viewer for .doc files or Adobe Acrobat for .pdf files.

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