Prior Authorization (PA) Requirements for Out-of-State Providers
- PA Requirements for Out-of-State Providers (01/01/2023) - Requirements for ALL Medicaid members (including ACO-attributed members)
Applied Behavior Analysis
- ABA Medical Prior Authorization Form (12/16/2021)
Mental Health
- VT Medicaid Admission Notification Form for Inpatient Psychiatric & Detoxification Services for In & Out of State Providers (01/01/2022) - TYPE IN
- VT Medicaid Admission Notification Form for Inpatient Psychiatric & Detoxification Services for In & Out of State Providers (01/01/2022) - WRITE IN
- VT Medicaid Child/Adolescent Inpatient Admission Notification - TYPE IN To be provided by the Designated Agency/SSA conducting the screening(01/31/2020)
- VT Medicaid Request for Per Diem Rate for Mental Health Extended Stays in Emergency Departments (01/01/2023) - TYPE IN
- VT Medicaid Request for Per Diem Rate for Mental Health Extended Stays in Emergency Departments (01/01/2023) - WRITE IN
- Request for Reconsideration: For Mental Health and Applied Behavior Analysis Services (10/01/2023)
Chiropractic
- Chiropractic Services Prior Authorization (11/22/2023)
Durable Medical Equipment
Please use the Medical Necessity, General form found below when there isn’t a specific form for requested service or equipment.
- Airway Clearance (12/05/2022)
- Adaptive Positioning Device (04/11/2023)
- Augmentative Communication Device (12/22/2022)
- Compression Garments Order Form (04/11/2023)
- Durable Medical Equipment (DME):
- Ownership, Operation, and Maintenance Agreement (11/18/2021)
- Recycled DME Ownership, Operation, and Maintenance Agreement (10/24/2022)
- Eyeglasses -Medical Necessity (04/11/2023)
- Foot Orthotic Tool, custom (11/1/2023)
- Medical Necessity, General (orthotics, prosthetics, medical supplies, and durable medical equipment) (04/11/2023)
- Non-Invasive Airway Assistance Devices (CPAP,BiPAP,AutoPAP) (04/11/2023)
- Orthotic Tool - (See Foot Orthotic Tool, custom)
- Shower Chair Form (04/11/2023)
- TENS Evaluation Tool (04/11/2023)
- Wheelchair Rule, Definitions and Coding information for Vermont Medicaid Members (12/01/2022)
- Vendor and Therapist Acknowledgement (12/01/2022)
- Wheelchair Form : Positioning Evaluation and Prescription Form (12/01/2022)
- Wheelchair: Basic AND Rental: Evaluation and Prescription Form (04/11/2023)
Laboratory and Radiology
- Genetic Testing Prior Authorization (03/22/2023)
- Urine Drug Test Prior Authorization (07/26/2010)
Out-of-Network
- Out-of-Network Elective Office Visit Request Form (12/6/2023)
- Out-of-Network Preadmission Request Form (11/1/2023)
- Out-of-Network Urgent and Emergent Admission Notification Form (04/10/2023)
- See pre-procedure form below
Pharmacy
Procedures
- Abortion Certification 219A (06/11/2014)
- Abortion Certification 219B (06/11/2014)
- Hysterectomy Consent (05/05/2015)
- Pre-Procedure Request Form (02/10/2023)
- Sleep Study Form (05/24/23)
- Sterilization Consent Form (09/01/2022)
Therapy
- Therapy Extension Form, PTOTST, Pediatric Services (does not include home health agencies) (4/11/2023)
- Therapy Extension Form, PTOTST, Adult Services (does not include home health agencies) (4/11/2023)
- Therapy Extension Form, PTOTST, Adult and Pediatric Services (home health services only) (4/11/2023)
- Cover Sheet, PTOTST (1/1/2023)
Uniform Medical, Mental Health and Behavioral Health Prior Authorization Form
- Uniform Medical Prior Authorization Form (12/2016)