Pay per submission with credits or a one-time card payment. Cost depends on patient or provider use and delivery method. No monthly subscription is required.
Medical office pricing per submission
Fax: 5 credits, or $4.99 by card when credits are insufficient.
Portal, phone or mail: 3 credits, or $2.99 by card when credits are insufficient.
Office approval is separate from payment. Personal and shared office credit balances are separate.
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)
- 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
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
Sign up free — pay by card or credits.
⚠️ BAA required for PHI
Self-service FaxSeal is not authorized for PHI. Do not use this provider workflow for HIPAA-regulated PHI unless your organization has a countersigned Enterprise BAA and written implementation approval.
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