Ambetter Out Patient PDF Details

Navigating healthcare bureaucracy can often feel overwhelming, but forms like the Ambetter Out Patient Authorization Form play a crucial role in ensuring patients receive the necessary outpatient services in a timely manner. This form serves as a request document for healthcare providers to obtain prior approval from Ambetter for outpatient procedures, ensuring that the services provided are within the scope of the patient’s plan and deemed medically necessary. It meticulously outlines the information required from healthcare providers, including Member Information, Ordering Provider Information, and details about the Servicing Provider or Facility. Specific sections are dedicated to detailing the requested service, including procedure codes, diagnosis codes, and service dates, reflecting the comprehensive nature of the information needed to process a request. The form delineates between standard and urgent requests, emphasizing the importance of timeliness in situations where urgent medical intervention is needed to prevent complications. Additionally, it lists a wide range of outpatient services, from genetic testing to transplants and mental health services, highlighting the extensive care coordination facilitated by this form. Importantly, it stresses the necessity of completing all required fields and accompanying the request with supporting clinical information to avoid delays in authorization. A disclaimer cautions that an authorization does not automatically guarantee payment; it underscores the importance of eligibility and the alignment of the requested services with covered benefits under the Ambetter policy. Moreover, it addresses the responsibility of healthcare providers to maintain the confidentiality of the information in compliance with HIPAA regulations, ensuring the privacy and protection of patient data. Through this detailed and mandatory process, the Ambetter Out Patient Authorization Form acts as a critical checkpoint in managing patient care, streamlining administrative procedures, and maintaining the integrity of confidential patient information.

QuestionAnswer
Form NameAmbetter Out Patient
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesambetter auth form, ambetter prior authorization form medication, ambetter authorization form, ambetter precertification

Form Preview Example

OUTPATIENT

AUTHORIZATION FORM

Complete and Fax to: Medical 855-218-0592 Behavioral 833-286-1086 Transplant 833-552-1001

Request for additional units.

Existing Authorization

Units

Standard requests - Determination within 5 calendar days of receiving all necessary information.

Urgent requests -

I certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within

48 hours to avoid complications and unnecessary suffering or severe pain.

 

 

 

 

 

 

URGENT REQUESTS MUST BE SIGNED BY THE

 

 

 

X

 

 

* INDICATES REQUIRED FIELD

 

 

 

REQUESTING PHYSICIAN TO RECEIVE PRIORITY.

 

 

 

 

*Date of Birth

MEMBER INFORMATION

 

 

 

 

 

 

 

*Member ID

 

 

 

Last Name, First

 

(MMDDYYYY)

 

 

 

 

 

 

ORDERING PROVIDER INFORMATION

 

 

 

*Ordering NPI

 

 

*Ordering TIN

 

Ordering Provider Contact Name

Ordering Provider Name

 

 

 

Phone

 

*Fax

*0687*

SERVICING PROVIDER / FACILITY INFORMATION

Same as Ordering Provider

 

 

*Servicing NPI

*Servicing TIN

Servicing Provider Contact Name

Servicing Provider/Facility Name

Phone

Fax

AUTHORIZATION REQUEST

*Primary Procedure Code

Additional Procedure Code

 

*Start Date OR Admission Date

*Diagnosis Code

(CPT/HCPCS)

(Modifier)

(CPT/HCPCS)

(Modifier)

(MMDDYYYY)

(ICD-10)

Additional Procedure Code

 

Additional Procedure Code

 

End Date OR Discharge Date

Total Units/Visits/Days

(CPT/HCPCS)

(Modifier)

(CPT/HCPCS)

(Modifier)

(MMDDYYYY)

 

*OUTPATIENT SERVICE TYPE

(Enter the Service type number in the boxes)

412 Auditory

712Cochlear Implants & Surgery

922Experimental and Investigational Services

205Genetic Testing & Counseling

249Home health

390Hospice Services

290Hyperbaric Oxygen Therapy

997Office Visit/Consult

794Outpatient Services

299Drug Testing

202Pain Management

171Outpatient Surgery

650Radiation Therapy

201Sleep Study

993Transplant Evaluation

209Transplant Surgery

724Transportation

DME

 

 

417

Rental

 

120

Purchase

(Purchase Price)

 

 

Behavioral Health-please send all supporting forms and medical records as necessary based on service

515Electroconvulsive Therapy

516Intensive Outpatient Therapy

518Mental Health /Chemical Dependency Observation

521Psychological Testing

512

Community Based Services - circle appropriate option: ABA Services

TMS

510

Medical Management

 

519

Outpatient Therapy

 

522 Psychiatric Evaluation

 

514

Day Treatment - Partial Hospitalization Program

 

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 prior authorization as per Ambetter policy and procedures.

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 destroy this document.

Rev. 09 03 2020 EW-PAF-0687

How to Edit Ambetter Out Patient Online for Free

With the objective of allowing it to be as effortless to apply as possible, we developed our PDF editor. The process of filling in the ambetter authorization is going to be hassle-free in case you stick to the following actions.

Step 1: Initially, press the orange button "Get Form Now".

Step 2: Right now, you can begin modifying the ambetter authorization. Our multifunctional toolbar is readily available - insert, delete, modify, highlight, and undertake similar commands with the content material in the file.

These particular areas will compose the PDF file that you will be filling in:

part 1 to filling in ambetter precertification

Note the appropriate information in Servicing NPI, Servicing TIN, Servicing Provider Contact Name, Servicing ProviderFacility Name, Phone, Fax, AUTHORIZATION REQUEST, Primary Procedure Code, Additional Procedure Code, Start Date OR Admission Date, Diagnosis Code, CPTHCPCS, Modifier, CPTHCPCS, and Modifier area.

Completing ambetter precertification step 2

You will need to put down some information within the area Auditory Cochlear Implants, DME Rental Purchase, Purchase Price, Behavioral Healthplease send all, ALL REQUIRED FIELDS MUST BE FILLED, Disclaimer An authorization is not, and Rev EWPAF.

part 3 to completing ambetter precertification

Step 3: Select the Done button to save your form. Now it is accessible for export to your gadget.

Step 4: You can generate duplicates of your form toavoid all possible problems. You need not worry, we don't share or track your data.

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