FORMS

The following forms are for services requiring prior authorization. Please complete and submit the request before providing the service to a member. For information regarding the Idaho Medicaid Behavior Modification and Consultation Program, please refer to the Provider Express portal by clicking here.

Service Request Forms for In-Network Providers

Service Request Forms for Out-of-Network Providers

Other Forms

Idaho Administrative Code ( IDAPA) 16.03.09.880-883 defines Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Services as Medically necessary services for eligible Medicaid participants under 21 years of age. EPSDT services are health care, diagnostic service, treatment and other measures described in section 1905(a) of the Social Security Act (SSA) necessary to correct or ameliorate defects, physical and mental illness, and conditions discovered by the screening services as defined in Section 1905(r) of the SSA, whether or not such services are covered under the State Plan. Services authorized must be considered, safe, effective, and meet acceptable standards of medical practice, and shall require prior authorization. Services are not covered for cosmetic, convenience, or comfort reasons.

The EPSDT Service request form is used to request prior authorization for outpatient behavioral health services for a child under 21 years of age that are deemed medically necessary and are not covered by the Idaho Behavioral Health Plan. For additional information on EPSDT and instructions on how to request EPSDT services please see: Optum Idaho Provider Manual > Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Services.
Early Periodic Screening Diagnosis Treatment (EPSDT) Form
Field Care Coordinator Referral Form

*Please call the Optum Idaho Provider Line at (855) 202-0983 Option 1 for form log in and form submission issues.*

Provider Clinical Questions: (855) 202-0983  | Primary Care Provider Psychiatric Consult press option 1