Virginia's Department of Medical Assistance Services uses the DMAS-363 for fee-for-service service authorization of outpatient services: DME, outpatient rehabilitation, prosthetics, home health, MRI, CT and PET scans, and EPSDT orthotics, hearing aids and assistive technology. A clinician meets it when ordering one of these for a member outside managed care. DMAS's contractor, Acentra Health, reviews it against InterQual and DMAS criteria.
The requesting provider completes all fields, including service type, severity of illness, intensity of services and line items. The ordering practitioner's orders, plan of care or certificate of medical necessity supply the clinical content and units.
Download the current version from the source each time; forms change without notice.
Outpatient Service Authorization Request
This form is a Word template, not a PDF. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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The instructions say only information provided on the contractor's forms can be entered, and not to send attachments or other forms with the fax. Put the clinical detail in the severity of illness and intensity of services blocks, which the instructions call the most critical parts of the form, and use additional comments for anything else.
For non-emergency outpatient MRI, CT and PET scans, a required question asks in what state the scan will be performed. Out-of-state services are covered only for set reasons, such as a medical emergency or services more readily available in the other state, and the form asks why Virginia providers cannot do it.