Idaho Medicaid uses this one-page form to request prior authorization for surgeries and procedures that are not reviewed by its utilization management contractor, Telligen. A surgeon's or physician's office meets it when a planned procedure needs Medicaid approval outside Telligen's scope. The office lists CPT codes, quantities and dates, identifies the physician and any facility by NPI, and faxes the form with supporting medical records.
The physician's office completes the entire form: participant details, physician and submitter contact, facility information, and the requested CPT codes with modifiers, quantities and dates of service. The participant does not complete any part.
Download the current version from the source each time; forms change without notice.
Idaho Medicaid Surgery & Procedure Prior Authorization Form
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Use it for surgeries and procedures that Telligen, Idaho Medicaid's utilization management contractor, does not review. Most outpatient, imaging and inpatient prior authorizations go through the Telligen portal; this Department form covers the remaining procedures and is faxed with the supporting medical records.
The form asks for all medical documentation that supports medical necessity, for example physician notes, consultations, operative reports or medical records from the last six months. Fax them with the completed form, which itself identifies only the participant, physician, facility, CPT codes, quantities and dates.