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Prior Authorization Listing for Concurrent Review, Step/Transfer Review, or Discharge

Effective Date:

(MMDDYYYY)

Expiration Date:

(MMDDYYYY)

Inpatient

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Auth #	Effective Date	Member ID #	Member DOB	Provider ID	Vendor ID	Level of Service	Type Of Service	Level of Care	Type of Care
Client Auth #	Expiration Date	Member Name	Member DOB	Provider Alt. ID	Alternate Provider	Level of Service	Type Of Service	Level of Care	Type of Care
01- 031419- 1- 12	03/14/2019	987654321	12/02/1979	123456	A00001	INPATIENT/HLOC	SUBSTANCE USE	INTENSIVE OUTPATIENT	INTENSIVE OUTPATIENT
	05/13/2019	ASLAN, SUSAN		712345
01- 030119- 1- 4	03/01/2019	987654321	12/02/1979	123456	A00001	INPATIENT/HLOC	SUBSTANCE USE	INTENSIVE OUTPATIENT	INTENSIVE OUTPATIENT
	04/30/2019	ASLAN, SUSAN		712345
01- 031419- 1- 13	03/15/2019	987654321	12/02/1979	123456	A00001	INPATIENT/HLOC	SUBSTANCE USE	ICF-A (INPATIENT REHAB)	LEVEL 3.5 INPATIENT
	04/13/2019	ASLAN, SUSAN		712345
01- 112918- 34- 39	11/29/2018	987654321	12/02/1979	123456	A00001	INPATIENT/HLOC	SUBSTANCE USE	INTENSIVE OUTPATIENT	INTENSIVE OUTPATIENT
	04/02/2019	ASLAN, SUSAN A		712345
01- 032719- 1- 9	03/27/2019	987654321	12/02/1979	123456	A00001	INPATIENT/HLOC	MENTAL HEALTH	Inpatient	IP MM- ACUTE
	03/31/2019	ASLAN, SUSAN		712345

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Outpatient

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Auth #	Effective Date	Member ID	Member DOB	Provider ID	Vendor ID	Level of Service	Type Of Service	Level of Care	Type of Care
Client Auth #	Expiration Date	Member Name	Member DOB	Provider Alt. ID	Alternate Provider	Level of Service	Type Of Service	Level of Care	Type of Care
01- 022619- 1- 19	02/26/2019	987654321	12/02/1979	123456	A00001	OUTPATIENT/COMMUNITY BASED	MENTAL HEALTH	Outpatient	OPMH NON OMS
	03/21/2020	ASLAN, SUSAN A		712345
01- 031919- 1- 2	03/19/2019	987654321	12/02/1979	123456	A00001	OUTPATIENT/COMMUNITY BASED	SUBSTANCE USE	Outpatient	OUTPATIENT ASSESS
	03/19/2020	ASLAN, SUSAN		712345
01- 120618- 66- 11	12/06/2018	987654321	12/02/1979	123456	A00001	OUTPATIENT/COMMUNITY BASED	SUBSTANCE USE	Outpatient	OUTPATIENT ASSESS
	12/06/2019	ASLAN, SUSAN R		712345
01- 120518- 54- 4	12/05/2018	987654321	12/02/1979	123456	A00001	OUTPATIENT/COMMUNITY BASED	SUBSTANCE USE	Outpatient	OUTPATIENT ASSESS
	12/05/2019	ASLAN, SUSAN P		712345
01- 120518- 62- 34	12/05/2018	987654321	12/02/1979	123456	A00001	OUTPATIENT/COMMUNITY BASED	SUBSTANCE USE	Outpatient	OUTPATIENT ASSESS
	12/05/2019	ASLAN, SUSAN		712345

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