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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.

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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 $1.99 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.

Submission checklist

○Your name, date of birth, member ID

○Your situation described (min 50 chars · 0 entered)

○Insurer fax number

○AI appeal letter generated & reviewed

0 of 4 checks complete

Prior Authorization Request

1. Your Doctor's Information(optional — helps strengthen your appeal)

Doctor Name

NPI (10 digits)

Practice / Clinic Name

Doctor Phone

Doctor Fax

2. Your Information & Insurance

Patient Name *

Date of Birth * (MM/DD/YYYY)

Member ID *

Group Number

3. Clinical Details(optional — include if known)

ICD-10 Code (if known)

Diagnosis (if known)

CPT Code (if known)

Denied Treatment / Procedure

Urgency

4. Your Medical Situation

Describe your situation in your own words *(min 50 chars)0/10000

Explain why you need this treatment, what your doctor has recommended, and what happened when the insurer denied it. The more detail you provide, the stronger your appeal.

5. AI Appeal Letter

Privacy notice: Clicking “Generate with AI” sends your description to OpenAI to draft your appeal letter. Do not include sensitive information beyond what is medically relevant.

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 →