Directions for Completing a PAR Form for Services Other than EPSDT Home Health

When completing a PAR form, it is important to include the client’s MEDICAID Identification Number. This number should be a letter followed by six digits. Please do not use the client’s social security number, as this will slow down processing because CFMC will have to request the correct ID number from the provider.

The PAR form, as well as supporting documentation, needs to be legible. If you are faxing the PAR and the information, be aware that sometimes the FAX process reduces the legibility.

Please read the following step-by-step instructions which refer to the Field Numbers on the PAR form:

1. Client Name                                                                                 (Required)
Enter the client's last name, first name, and middle initial exactly as it appears on the eligibility verification. Example: Adams, Mary A.

2. Client Identification Number                                                        (Required)
This number consists of a letter prefix followed by six numbers. Enter the client's state identification number exactly as it appears on the eligibility verification.
Example: A123456.

3. Gender                                                                                         (Required)
Enter an "X" in the appropriate box.

4. Date of Birth                                                                                 (Required)
Enter the client's birth date exactly as it appears on the eligibility verification using MMDDYY format. Example: January 1, 2003 = 010103.

5. Client Address                                                                              (Required)
Enter the client's full address: Street, city, state, and zip code.

6. Client Telephone Number                                                            (Optional)
Enter the client’s telephone number.

7. Prior Authorization Number                                                         (Leave Blank)
Do not write in this area.

8. Dates Covered by This Request                                                   (Optional)
Enter the date(s) within which service(s) will be provided. If left blank, dates are entered by the authorizing agent. Authorized services must be provided within these dates.

9. Does Client Reside in a Nursing Facility?                                     (Required)
Check the appropriate box.

10. Group Home Name if Patient Resides in a Group Home            (Conditional)
Complete if client resides in a group home. Enter the name of the group home or residence.

11. Diagnosis Code                                                                          (Required)
Enter the ICD-9 diagnosis code. Separate documentation must be submitted (not included in this field) which gives sufficient relevant diagnostic information to justify the request. Include the prognosis. Provide relevant clinical information, other drugs or alternative therapies tried in treating the condition, results of tests, etc., to justify a Colorado Medical Assistance Program determination of medical necessity. Approval of the PAR is based on documented medical necessity. Include documents (including questionnaires) as required.

12. Requesting Authorization for Repairs                                        (Conditional)
Complete if requesting repairs for equipment owned by the client. (PAR requests for repairs for any wheelchair are to be sent to ACS, not CFMC.) Enter the serial number of the equipment.

13. Indicate Length of Necessity                                                      (Conditional)
Complete if renting equipment. Provide best estimate of how long equipment will be needed.

14. Estimated Cost of Equipment                                                     (Conditional)
Complete if purchasing, replacing, or repairing equipment. Provide best estimate of cost for labor and replacement part(s) for repair or cost for purchases.

15. Services To Be Authorized                                                         (Preprinted)
Do not alter preprinted lines. No more than five items can be requested on one form.

16. Describe Procedure or Supply to be Provided                           (Required)
Enter the description of the service/procedure to be provided.

17. Procedure or Supply Code                                                         (Required)
Enter the HCPCS code for each item that will be billed on the claim form. The authorizing agent may change any code. The approved code(s) on the PAR form [the determination letter from ACS] must be used on the claim form.

18. Number of Services                                                                    (Required)
Enter the number of units for supplies, services or equipment requested. If this field is blank, the authorizing agent will complete with one unit.

19. Authorized Number of Services                                                 (Leave Blank)
The authorizing agent indicates the number of services authorized which may or may not equal number requested in Field 18 (Requested Number Of Services).

20. A=Approved D=Denied                                                              (Leave Blank)
No longer used. Providers should check the PAR on-line or refer to the PAR letter.

21. Primary Care Physician (PCP) Name                                         (Conditional)
Complete if client has a PCP. Enter the PCP’s name as it appears on the current eligibility verification.

22. Primary Care Physician Address                                                (Conditional)
Complete if client has a PCP. Enter the PCP’s complete address.

23. PCP Provider Number                                                                (Conditional)
Complete if client has a PCP. Enter the PCP’s eight-digit Colorado Medical Assistance provider number. This number must be obtained by contacting the PCP for the necessary authorization.

24. Name and Address of Provider Requesting Prior Authorization (Required)
Enter the complete name and address of the physician requesting prior authorization (the physician ordering/writing the prescription).

25. Name and Address of Provider Who will Render Service          (Required)
Enter the name, address, and telephone number of the supplier who will render the service.

26. Requesting Physician Signature                                                (Required)
The requesting provider must sign the PAR and must be the physician ordering the service. The telephone number of the requesting provider is also required. Under unusual circumstances, when the prescribing physician is not available, a legible copy of a signed prescription may be attached in place of the signature of the requesting provider. The written diagnosis must be entered in Field 11 (Diagnosis), even if a prescription form is attached. Do not send the original prescription; send a photocopy on an 8½ x 11 sheet. A rubber stamp facsimile signature is not acceptable on the PAR.

27. Date Signed                                                                               (Required)
Enter the date the PAR form is signed by the requesting provider.

28. Provider Number                                                                       (Required)
Enter the eight-digit Colorado Medical Assistance Program provider number of the requesting provider.

29. Service Provider Number                                                          (Required)
Enter the eight-digit Colorado Medical Assistance Program provider number of the rendering provider. The rendering provider must be enrolled in the Colorado Medical Assistance Program.

30. Comments or Reasons For Denial of Benefits                           (Leave Blank)
Providers should check the PAR on-line or refer to the PAR letter.

31. PA Number Being Revised                                                        (Conditional)
Complete if revising the original PAR. Enter the prior authorization number of the original PAR that is being revised. [This number will be a letter, usually a “B”, followed by six digits.]

In all cases, fields 25 and 29 must be the name and number of the provider who will bill for the services (not necessarily the provider who will render the services). This is the number that ACS will match to the billing provider on the incoming claim. This field might contain the number of a clinic, a physician group, a hospital, or whatever entity will be listed as the billing provider on the claim.

For PT/OT Prior Authorization Requests, fields 24, 26, and 28 may sometimes not be used for the requesting provider/physician. If an independent practitioner will bill the PAR, those fields are used for the name and Medicaid provider number of the therapist.