Submit Authorization Request Page
The Submit Authorization Request page confirms submission of your service authorization request.
Service Authorization Info Fields
| Field | Description |
|---|---|
| Service Authorization ID | The identification number of the service authorization. |
| Requesting Provider ID/Type |
Indicates the type of provider identifier being used for the authorization. Examples: Medicaid ID, Provider UPIN Number, Facility ID Number |
| Requesting Provider ID / Type | The provider id of the requesting physician and their provider ID type. |
| Provider Name | The name of the billing provider on the submitted service authorization. |
| Member ID |
Unique identifier used for a member and is assigned when the member becomes eligible to receive Medicaid benefits. |
| Member Name | The name of person identified in the submitted service authorization. |
| Certification Action |
The certification status of the authorization that has been submitted or saved. It is the HIPAA value for the header status of the authorization. Examples: Certified - Partial, Not Certified, Pended, Modified, Cancelled, Contact Payer, No Action Required |
| Submission Date/Time | The date and time the service authorization was submitted. |
| Additional Documentation | |
| Type of Attachment | Long description list of attachments that are still outstanding and need to be sent in to the mailing address. |
| Mailing Address | |
| Mailing Address | Lists the mailing address to send the additional documents to. |