A telephone review shall include the following:
(1) Initiation of phone request by a provider
authorized to request prior authorization as listed in section 10 of this
(2) The name, address, age,
and Medicaid number of the member.
(3) The name, address, telephone number, and
provider number of the provider.
(4) Diagnosis and related
(5) Services or
supplies requested (CPT or HCPCS code).
(6) Name of suggested provider of services or
clinical information required to establish that the service is medically
necessary, including the following:
history, including results of diagnostic studies.
(B) Prior treatment.
(C) Rationale for treatment plan.
(D) Comorbid conditions.
(E) Treatment plan.
(G) Date of onset of medical
Additional information may be required as needed for clarification, including,
but not limited to, the following:
(C) Other services being received.
For emergency admissions, the
following information is required, where applicable:
(A) Type of accident.
(B) Accident date.
(10) Diagnosis code.