Get Ambetter Outpatient Authorization Form 2016

OUTPATIENT Prior Authorization Fax Form Request for additional units. Existing Authorization Fax to 855-537-3447 ICD-9 Units ICD-10 Urgent Request - I certify this request is urgent and medically necessary to treat an injury illness or condition not life threatening within 72 hours to avoid complications and unnecessary suffering or severe pain* URGENT REQUESTS MUST BE SIGNED BY THE REQUESTING PHYSICIAN TO RECEIVE PRIORITY. X INDICATES REQUIRED FIELD Date of Birth MEMBER INFORMATION Member ID REQUESTING PROVIDER INFORMATION Requesting NPI MMDDYYYY Last Name First Standard Request - Determination within 15 calendar days of receiving all necessary information Requesting Provider Contact Name Phone Fax SERVICING PROVIDER / FACILITY INFORMATION Same as Requesting Provider Servicing NPI Servicing Provider/Facility Name AUTHORIZATION REQUEST Primary Procedure Code CPT/HCPCS Start Date OR Admission Date Diagnosis Code Modifier Total Units/Visits/Days OUTPATIENT SERVICE TYPE Fill in the square with an X Air Ambulance Fixed Wing Genetic Testing Biopharmacy Home Health Chiropractic Hospice Outpatient Cochlear Implants and Surgery Observation Stay DME OB Ultrasound Enteral Feedings End Date OR Discharge Date Additional Procedure Code Parenteral Feedings Office Visit Other Site Orthotics Outpatient Services Pain Management Prosthetics Quantitative Urine Drug Screen Sleep Study Home Surgical Procedures ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED. COPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION* Disclaimer An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered* Services must be a covered benefit and medically necessary with Confidentiality The information contained in this transmission is confidential and may be protected under the Health Insurance Portability and Accountability Act of 1996. If you are not the intended recipient any use distribution or copying is strictly prohibited* If you have received this facsimile in error please notify us immediately and TX-PAF-0588 destroy this document.