Ambetter Inpatient Prior Authorization Form PDF Details

If you are a provider seeking inpatient admission for a patient, you will need to complete an Ambetter Inpatient Prior Authorization Form. This form is used to assess the appropriateness of inpatient admission and to ensure that patients receive the most appropriate level of care. The form can be completed online or by fax. Providers should allow enough time for the prior authorization process, which can take up to 72 hours. Thank you for your cooperation.

QuestionAnswer
Form NameAmbetter Inpatient Prior Authorization Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesambetter illinois prior authorization form, ambetter inpatient prior pdf, ambetter inpatient prior form, ambetter health insurance

Form Preview Example

INPATIENT

Fax to: 855-702-7337

 

Prior Authorization Fax Form ICD-9 ICD-10

Standard Request - Determination within 15 calendar days of receiving all necessary information

 

Expedited 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 sufering or severe pain.

 

 

 

 

URGENT REQUESTS MUST BE SIGNED BY THE

*0603*

X

 

REQUESTING PHYSICIAN TO RECEIVE PRIORITY.

 

 

* INDICATES REQUIRED FIELD

 

 

 

MEMBER INFORMATION

 

Date of Birth *

 

 

 

 

Member ID*

 

Last Name, First

(MMDDYYYY)

 

 

 

 

REQUESTING PROVIDER INFORMATION

 

 

Requesting NPI*

 

Requesting TIN *

Requesting Provider Contact Name

 

Requesting Provider Name

 

Phone

Fax

 

SERVICING PROVIDER / FACILITY INFORMATION

 

 

Same as Requesting Provider

 

 

 

Servicing NPI *

 

Servicing TIN *

Servicing Provider Contact Name

 

Servicing Provider/Facility Name

 

Phone

Fax

 

AUTHORIZATION REQUEST

 

 

 

Primary Procedure Code

 

Start Date OR Admission Date *

Diagnosis Code *

 

(CPT/HCPCS)

(Modiier)

(MMDDYYYY)

(ICD-9)

 

Additional Procedure Code

 

End Date OR Discharge Date

 

 

(CPT/HCPCS)

(Modiier)

(MMDDYYYY)

 

 

INPATIENT SERVICE TYPE*

(Fill in the square with an X)

 

 

Comprehensive Inpatient

Inpatient Rehab Hospital

Medical

Surgical

Rehab Facility

 

 

 

 

 

Delivery

 

Long Term Acute Care (not Rehab)

Premature / False Labor

Transplant

C-Section

 

Nursing Home

Skilled Nursing Facility

 

 

 

 

 

Vaginal Delivery

 

Skilled Nursing Facility

 

 

 

 

 

 

 

 

 

Sub-Acute

 

Hospice Inpatient

 

Inpatient Hospital

 

 

 

 

 

 

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 beneit and medically necessary with prior authorization as per Ambetter policy and procedures.

Confidentiality: The information contained in this transmission is conidential 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 destroy this document.

IN-PAF-0603

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This PDF form will require particular information to be entered, thus you should definitely take the time to fill in what is asked:

1. Fill out your ambetter inpatient prior authorization fax form with a group of major blanks. Collect all of the necessary information and make sure nothing is overlooked!

Step # 1 for filling out ambetter inpatient prior authorization form

2. Given that the previous array of fields is done, you have to put in the required specifics in Servicing ProviderFacility Name, Phone, Fax, AUTHORIZATION REQUEST, Primary Procedure Code, Start Date OR Admission Date , Diagnosis Code , CPTHCPCS, Modiier, MMDDYYYY, ICD, Additional Procedure Code, End Date OR Discharge Date, CPTHCPCS, and Modiier so you're able to move on further.

Tips on how to prepare ambetter inpatient prior authorization form portion 2

Always be really attentive while filling out CPTHCPCS and Diagnosis Code , since this is where many people make errors.

Step 3: Prior to moving on, you should make sure that blank fields have been filled in right. Once you are satisfied with it, click “Done." Sign up with FormsPal right now and instantly use ambetter inpatient prior authorization fax form, ready for download. All modifications you make are kept , meaning you can change the document at a later time if required. We don't sell or share the details that you provide whenever completing documents at FormsPal.

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