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Connecticut HUSKY Outpatient Prior Authorization Form

Connecticut Medicaid's HUSKY Health program uses this request for prior authorization of outpatient services managed by Community Health Network of Connecticut (CHNCT): medical and surgical services, DME and customized wheelchairs, orthotics and prosthetics, therapies, chiropractic, home health, hearing aids, oxygen, hospice and vision care. HUSKY runs as one statewide program without managed care plans, so a single form serves every member.

Who completes it

The billing provider fills in items 1 to 24, including the referring physician's details in item 6, the member's information and up to eight service lines. The clinical practitioner writes the clinical statement in item 25, with prognosis and rehabilitation potential, and signs it.

Submitting and payment

How to submit it
Fax the form to CHNCT or enter the request in the CHNCT Medical Authorization Portal; home care requests must go through the portal. A current plan of treatment and progress notes must be attached.
Who pays
Item 24 asks the billing provider to enter the total dollar cost of the units requested on each service line, where applicable.

Good to know

  • Signature stamps are not accepted on item 25. The clinical practitioner's signature is optional only for initial home health and therapy requests.
  • For physical, occupational and speech therapy, mark whether the request is initial or a re-authorization; for independent chiropractic, mark evaluation, initial authorization or re-authorization.
  • Hospice requests need added justification: general inpatient hospice beyond five days must explain why symptoms cannot be managed elsewhere, and hospice beyond 12 months must explain why it remains indicated.
  • Advanced imaging is not requested on this form; it goes to eviCore. Customized wheelchair requests pair with the separate Wheeled Mobility Letter of Medical Necessity Form.

Get the official form

Download the current version from the source each time; forms change without notice.

Outpatient Prior Authorization Form

Official pagePDF

How this list is checked

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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Frequently asked questions

Can the HUSKY outpatient prior authorization form be typed?

Yes. The PDF has fillable fields, and CHNCT accepts it typed or printed and handwritten. Either way, attach the current plan of treatment and progress notes showing the necessity, effectiveness and goals of the requested service, and sign item 25 without a signature stamp.

What goes in the clinical statement on the HUSKY outpatient PA form?

Item 25 asks the clinical practitioner for a comprehensive statement of clinical necessity, the plan of treatment and the desired outcome, including prognosis and rehabilitation potential. Hospice requests for more than five days of general inpatient care, or for hospice beyond 12 months, need specific added explanations.

Which revision of the HUSKY outpatient PA form is current?

The footer reads UMPR-FM115253-1023, November 2023. Page 2 holds field-by-field instructions, such as entering the NPI as the Medicaid billing number (or the CMAP identification number if no NPI is available) and member details from the ConneCT card or AEVS.