DMAS VIRGINIA
Residential Treatment Care(Level C) Prior Authorization Request Fax Form "KePRO/DMAS now require any Medicaid Provider submitting Prior Authorizations using their National Provider Identifier (NPI) or Atypical Provider Identifier (API) to provide their 9 digit zip code. If you do not know your 9 digit zip code then please visit: http://zip4.usps.com/zip4/welcome.jsp" Initial Review Continued Stay Review Retro Authorization Change Request FAX: 1-877-OKBYFAX (877-652-9329) / Phone: 1-888-827-2884 ***Please More10) Provider Name: 11a.) Provider Address: 11b.) 9 digit Zip Code: .... This FAX submission form is required for Residential Treatment Care (RTC) prior Less
Not the form you were looking for?
Upload form
Not the form you were looking for?
Upload form
Please wait while form is uploaded and processed.
After you finish filling the form, you can Print, Email or Export your form. |
|