How to Fill Out and Submit a Mississippi Medicaid Prior Authorization Form

Submitting a Mississippi Medicaid prior authorization form starts with picking the right one: pharmacy requests use the Division of Medicaid’s one-page Pharmacy Prior Authorization form, non-pharmacy medical and surgical services go through Telligen, and patients enrolled in a MississippiCAN managed care plan use their plan’s own form instead. Match the form to the service, fill every required field, attach clinical documentation, and send it through the matching portal or fax line.

Pick the Right Form First

Mississippi runs two separate prior authorization tracks, and sending a request down the wrong one gets it rejected rather than reviewed.

For prescription drugs, download the standardized one-page Pharmacy Prior Authorization Request from the Division of Medicaid’s Drug Prior Authorization page at medicaid.ms.gov. The page lists drop-down menus by drug category so you can pull the correct PA packet for the specific medication.1Mississippi Division of Medicaid. Drug Prior Authorization

For medical and surgical services, inpatient admissions, and durable medical equipment, requests go through Telligen, the state’s utilization management organization. Providers submit through the Telligen portal at msmedicaid.telligen.com.2Mississippi Division of Medicaid. Prior Authorization

Before you submit anything, confirm the service actually requires authorization. The Division publishes a searchable spreadsheet of every procedure code that needs PA, organized by service area, at medicaid.ms.gov.3Mississippi Division of Medicaid. Procedure Code PA Requirement

Filling Out the Pharmacy Form

The pharmacy PA form is one page, but it asks for a lot of clinical detail. Blank or mismatched fields are the fastest route to a bounce-back.

Beneficiary, Prescriber, and Pharmacy Information

At the top, enter the beneficiary’s full name, date of birth, and Medicaid ID number. On the prescriber side, provide the full name, NPI, phone number, fax number, and mailing address. A separate section asks for the dispensing pharmacy’s NPI, name, phone, and fax. Reviewers use these fields to verify enrollment and reach out with follow-up questions, so none of them is optional.4Mississippi Division of Medicaid. Standardized One Page Pharmacy Prior Authorization Form

Drug and Diagnosis

In the clinical section, enter the drug or product name, strength, quantity, days supply, and number of refills. The pharmacy form identifies the medication by name and dosage, not by CPT or HCPCS codes. Add at least one ICD-10 diagnosis code explaining why the patient needs the drug.4Mississippi Division of Medicaid. Standardized One Page Pharmacy Prior Authorization Form

Clinical Criteria Questions

The bottom half drives the approval decision. Answer whether the drug has an FDA-approved indication for the patient’s diagnosis, whether a preferred agent on the state’s Preferred Drug List treats the same condition, and whether the patient tried and failed any preferred alternatives. If a preferred drug was tried, document which one, how long the patient took it, and why it failed, whether that was treatment failure, a drug interaction, or intolerable side effects.4Mississippi Division of Medicaid. Standardized One Page Pharmacy Prior Authorization Form

The form also asks whether the request would push an adult beneficiary over six prescriptions per month and whether the provider has reviewed the 90-day maintenance list. A “no” on the maintenance list question requires an explanation. The prescriber then signs an attestation that medical necessity outweighs any risk for the requested medication.

Supporting Documentation

Checkboxes let you indicate a recent hospital discharge or flag that additional medical justification is attached. For non-formulary drugs or medications with usage limitations, attach clinical notes, lab results, or treatment history showing why this drug is the right choice. Inadequate documentation is the most common cause of delays.

Filling Out a Non-Pharmacy Request

Medical and surgical requests use CPT or HCPCS procedure codes rather than drug names, along with ICD-10 diagnosis codes and clinical documentation supporting medical necessity. These go through the Telligen portal, not the Gainwell pharmacy portal.

Inpatient hospital admissions require Telligen authorization for virtually all admissions. The only exceptions are uncomplicated vaginal deliveries of two days or fewer, cesarean deliveries of four days or fewer, and well newborns staying five days or fewer. Emergency and urgent admissions still need authorization, but the deadline is the next working day after admission. Skipping authorization means denial of payment to every provider who billed for the stay, including the hospital and the attending physician.5Legal Information Institute. 23 Miss Code R 202-1.3 – Prior Authorization of Inpatient Hospital Services

If the Patient Is in a Managed Care Plan

A large share of Mississippi Medicaid beneficiaries get their benefits through MississippiCAN or the Children’s Health Insurance Program, and those enrollees are assigned to one of three coordinated care organizations: Magnolia Health, Molina Healthcare, or TrueCare. TrueCare replaced UnitedHealthcare Community Plan effective July 1, 2025, so any UnitedHealthcare references in older material are outdated.6Mississippi Division of Medicaid. How to Enroll/Contract with TrueCare Based on Enrollment with DOM

Each CCO maintains its own forms, portals, and phone lines. Submitting the state Fee-for-Service pharmacy form or a Telligen request for a managed care enrollee will come back rejected. Verify enrollment status and identify the correct CCO before you submit. Magnolia Health, for example, uses its own outpatient prior authorization fax form with its own fields for CPT/HCPCS codes, diagnoses, and clinical justification.7Magnolia Health Plan. Outpatient Medicaid Prior Authorization Fax Form The clinical standard of medical necessity stays the same, but the paperwork and phone numbers do not.8Mississippi Division of Medicaid. Managed Care

How and Where to Submit

For Fee-for-Service pharmacy requests, the Division of Medicaid prefers submission through the Gainwell provider web portal. You can also fax a completed form to 866-644-6147, or call the toll-free pharmacy PA line at 833-660-2402 for questions or status checks.1Mississippi Division of Medicaid. Drug Prior Authorization The state’s provider portal, now called MESA, is at portal.MS-Medicaid-MESA.com; providers who used the older interface log in with the same credentials.9Mississippi Division of Medicaid. MESA Portal for Providers

Non-pharmacy requests go through the Telligen portal at msmedicaid.telligen.com. Telligen handles both prospective requests before the service is delivered and retrospective reviews after an emergency or urgent service.2Mississippi Division of Medicaid. Prior Authorization

How Long Approval Takes

If a pharmacy PA has not come through and the patient has an immediate need, a pharmacist can dispense a 72-hour emergency supply using professional judgment. This is strictly for emergencies, not a routine workaround for pending requests.10Mississippi Division of Medicaid. General Prior Authorization Instructions

If the Request Is Denied

After a denial, the provider can either prescribe a different treatment that does not require authorization or request a first reconsideration by contacting the PA unit that handled the original review. For Fee-for-Service pharmacy denials, call 1-877-537-0722. Managed care plans have their own reconsideration lines.10Mississippi Division of Medicaid. General Prior Authorization Instructions

Beneficiaries can request a fair hearing when Medicaid denies, terminates, suspends, or reduces a covered service. The written request must go in within 30 days of the adverse action notice. Send it to:

Division of Medicaid
Attn: Office of Appeals
550 High Street, Suite 1000
Jackson, MS 39201

Federal regulations at 42 CFR 431.200 and Mississippi rules guarantee a fair and impartial hearing. The beneficiary can appear alone or be represented by legal counsel, a relative, a friend, or another spokesperson.13Legal Information Institute. 23 Miss Code R 300-2.1 – Authority for Applicant and Beneficiary Appeals