Prior authorization to State Medicaid (generic)

Medicaid is jointly funded by federal and state governments but administered independently by each state, which means PA processes, fax numbers, required forms, and clinical criteria all differ by state. Some states use single-page fax forms; others require electronic portal submissions with attachments. For patients under age 21, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) documentation is frequently required and often the reason for denial when missing. Contact your state Medicaid agency directly to obtain the current PA form and fax number before submitting.

🏛️

State Medicaid (generic)

Medicaid

PA Fax: Enter manually
PA Phone: —
Standard turnaround: 5 business days
Urgent turnaround: 72 hours

Each state has its own Medicaid PA process. Contact your state Medicaid office for the correct fax number and forms.

What you'll need

FaxPortalPhone

Form required

State-specific PA request form (varies by state)

☐Identify your state Medicaid agency and get state-specific PA form
☐Patient Medicaid member ID
☐ICD-10 diagnosis code(s)
☐CPT procedure code(s)
☐Clinical notes and medical necessity documentation
☐Prior treatment history (step therapy documentation)
☐EPSDT documentation if patient is under age 21
☐Ordering provider NPI and Medicaid provider number

▶Common denial reasons

⚠Service not on state Medicaid fee schedule or benefit list
⚠Missing state-specific required form
⚠Step therapy not documented — must show prior conservative treatment failed
⚠EPSDT documentation missing for pediatric patients

Verified 2026-05-20. Check payer site for current rules →

From $2.99 per submission

PA Agent requires an account so you can track submissions, record outcomes (approved/denied), and pre-fill appeals automatically. It's free to join.

You can preview the form below — sign in before generating or submitting.

⬆ Import from CSVDownload template

Submission checklist

○Provider name, NPI, practice name

○Provider phone & fax number

○Patient name, DOB, member ID

○ICD-10, diagnosis, CPT, procedure

○Clinical notes (min 50 chars · 0 entered)

○Fax destination number

○AI justification generated & reviewed

0 of 7 checks complete

Prior Authorization Request

1. Provider Information

Provider Name *

NPI * (10 digits)

Practice Name *

Provider Phone *

Provider Fax *

2. Patient & Insurance

Patient Name *

Date of Birth * (MM/DD/YYYY)

Member ID *

Group Number

💬 Patient notifications: add the patient's email below and they'll automatically receive an email when you record the insurer's decision on the tracking page — no phone call needed.

Patient Email (for outcome notifications)

Patient Phone (for future SMS notifications)

3. Clinical Details

ICD-10 Code *

Diagnosis Description *

CPT Code * (5 digits)

Procedure Description *

Urgency

4. Clinical Notes

Provider notes & supporting rationale *(min 50 chars)0/10000

5. AI Clinical Justification

PHI notice: Clicking “Generate with AI” sends clinical notes and diagnosis to OpenAI for processing. Do not include information beyond what is clinically necessary. Review your organization's policies before submitting patient data to third-party AI services.

6. Submission Method

Each state has its own Medicaid PA process. Contact your state Medicaid office for the correct fax number and forms. Find fax number →