Recipient medicaid identification number enter the

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Recipient Medicaid Identification Number ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Enter the recipient°s ten-digit Medicaid number. This can be found on the Medicaid Forward card. Procedure Code of Product Requested ____ ____ ____ ____ ____ Enter one requested procedure code per STAT-PA request. For touch-tone telephone users, the code will be entered as follows: L3216 = *53 3 2 1 6 L3221 = *53 3 2 2 1 A5500 = *21 5 5 0 0 Diagnosis Code ___________________________ Use the recipient°s International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) three- to six-digit diagnosis code. The decimal point for diagnosis codes is not required; however, all digits of the code must be entered. Place of Service Code ____ ____ The place of service codes for orthopedic shoes may be " 05 " (Indian Health Service Free-Standing Facility), " 06 " (Indian Health Service Provider-Based Facility), " 07 " (Tribal 638 Free-Standing Facility), " 08 " (Tribal 638 Provider-Based Facility), " 11 " (Office), " 12 " (Home), " 20 " (Urgent Care Facility), " 31 " (Skilled Nursing Facility), " 32 " (Nursing Facility), " 33 " (Custodial Care Facility), " 34 " (Hospice), " 50 " (Federally Qualified Health Center), " 54 " (Intermediate Care Facility/Mentally Retarded), " 71 " (State or Local Public Health Clinic), or " 72 " (Rural Health Clinic). Requested First Date of Service ____ ____ ____ ____ ____ ____ ____ ____ Use the eight-digit format MM/DD/YYYY. The first date of service entered may be up to 31 calendar days in the future. In the event that the STAT-PA system is unavailable at the time the shoes are provided, the PA request may be backdated up to four calendar days. Total Number Requested ____ STAT-PA REQUEST CHECKLIST All information must be entered for each category, both in the STAT-PA system and on this worksheet. 1. Enter the eight-digit signature date on the prescription in MM/DD/YYYY format. The prescription date cannot be more than six months in the past from the requested grant date. ____ ____ ____ ____ ____ ____ ____ ____ 2. Has the recipient received orthopedic shoes in the past? If yes, enter "1." If no, enter "2." ____ a. If yes, proceed to question 3. b. If no, proceed to question 5. 3. Did the recipient wear orthopedic shoes to the pedorthic examination? If yes, enter "1." If no, enter "2." ____ a. If yes, proceed to question 4. c. If no, the provider will receive the following message: ±Your prior authorization request requires additional information. Submit your request on paper with complete clinical documentation.² Continued
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STAT-PA ORTHOPEDIC SHOES WORKSHEET Page 2 of 2 HCF 11052 (Rev. 08/03) STAT-PA REQUEST CHECKLIST (Continued) 4. Are the recipient°s current shoes in disrepair? If yes, enter "1." If no, enter "2." ____ a. If yes, proceed to question 5. b. If no, the provider will receive the following message: ±Your prior authorization request requires additional information. Submit your request on paper with complete clinical documentation.² 5. Are the requested shoes manufactured by Drew, P.W. Minor, Markell, or Apex? If yes, enter "1." If no, enter "2." ____ a. If yes, proceed to step 6. b. If no, the provider will receive the following message: ±Your prior authorization request requires additional information. Submit your request on paper with complete clinical documentation.² 6. Enter the Mobility Level (MBL) that best describes the recipient. ____ MBL 1 The recipient walks in the community with or without the assistance of another person or an assistive device (enter "1").
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