Pennsylvania's Department of Human Services uses the MA 97 to request fee-for-service Medical Assistance prior authorization, or a program exception under the 1150 waiver, for outpatient services, equipment and supplies. A practitioner meets it when prescribing or requesting a service that needs approval for a fee-for-service beneficiary. The DHS copy goes to the outpatient prior authorization and 1150 waiver unit, which issues a notice.
The requesting provider completes the form from eligibility and PROMISe enrollment data, and the referring practitioner or prescriber signs item 35 attesting medical necessity. The patient or an authorized representative must also sign item 33.
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Outpatient Services Authorization Request
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Yes. Item 33 must be signed by the patient or an authorized representative, with the date in item 34. The practitioner or prescriber requesting the service signs item 35, or uses a signature stamp, attesting the service is medically necessary and the information is accurate.
No. The MA 97 is for fee-for-service Medical Assistance. Beneficiaries enrolled in a HealthChoices managed care organization go through that plan's prior authorization process, so confirm enrollment through the Eligibility Verification System before completing items 3 to 6.
Item 27 asks what other alternatives have been tried or used to meet the patient's needs. Attach documentation of those alternatives and why they did not work. If no alternatives have been tried or used, enter N/A rather than leaving it blank.