MO HealthNet uses form 2575-034 to request fee-for-service prior authorization for medical services, durable medical equipment, prostheses and Healthy Children and Youth (HCY, Missouri's EPSDT) services. Providers meet it when a service needs approval before delivery. A state consultant reviews up to 12 service lines, approves or denies each one, and sets the allowed amount for manually priced codes.
The requesting provider completes Sections I to IV and signs where the provider manual requires. The prescribing or performing practitioner completes and signs Section V for prescribed services such as DME or physical therapy, or when the requester is a clinic or group; signature stamps are not accepted.
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Prior Authorization Request
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The requesting provider signs Section IV when the provider manual requires it. The prescribing or performing practitioner must sign Section V for services that need a prescription, such as DME or physical therapy, or when the requesting provider is a clinic or group. Signature stamps are not acceptable in Section V.
No. The form states that authorization approves the medical necessity of the service but does not guarantee payment or that the amount billed will be reimbursed. The participant must be MO HealthNet eligible on the date of service or the date the equipment or prosthesis is received.