Provider Manual Exhibits

• Exhibit 3: Prospective/Precertification Request FAX Form
• Exhibit 5: Daily Inpatient Review Worksheet
• Exhibit 7: Concurrent Review Request FAX Form
• Exhibit 9: Psychiatric Admit Notification Information and Psychiatric Hospital Review Documentation Requirements (For Individuals Under the Age of 21)
• Exhibit 10: Psychiatric Worksheet for Prospective/Precertification Review (Clients 21 Years or Older)
• Exhibit 11: Psychiatric Review Worksheet for Recertification/Continued Stay Review (All Ages)
• Exhibit 12: Physical Rehabilitation Review Worksheet for Prospective/Precertification Review
• Exhibit 14: Retrospective Review Request Form
• Exhibit 15: Photocopying Invoice Idaho Medicaid
• Exhibit 16: (AND) Administratively Necessary Days Intake Form
• Exhibit 22: Notification of Birth: Anticipated Stays Greater than 72 Hours
• Exhibit 23: Sample Hysterectomy Questionnaire
• Exhibit 25: Sample IMD Questionnaire

Pre-Authorization List - July 2008 
Also known as Appendix A in the Provider Manual.

Checklist for Procedure Authorization Reviews

Qualis Health Retrospective Review Request Form

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