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Ambetter Out Patient is an innovative clinic for treating mental health issues.

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Ambetter Out Patient PDF Details

Tomorrow is my first day back at work after being out for three weeks due to an illness. I'm feeling much better, but I know that it will take me a few days to get back into the groove of things. My employer offers an Ambetter Out Patient plan, which allows employees to visit providers within the network without having to pay any out-of-pocket costs. This is great for me because I know that I won't have any surprises when I go to the doctor. Plus, the premiums are very affordable.

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Question	Answer
Form Name	Ambetter Out Patient
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	ambetter medication prior authorization form, ambetter precertification, ambetter prior authorization phone number, ambetter auth form

12

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
Urgent requests -	48 hours to avoid complications and unnecessary suffering or severe pain.
						URGENT REQUESTS MUST BE SIGNED BY THE
			X			URGENT REQUESTS MUST BE SIGNED BY THE
* INDICATES REQUIRED FIELD			X			REQUESTING PHYSICIAN TO RECEIVE PRIORITY.
* INDICATES REQUIRED FIELD						*Date of Birth
MEMBER INFORMATION						*Date of Birth
MEMBER INFORMATION
*Member ID				Last Name, First		(MMDDYYYY)
				Last Name, First
ORDERING PROVIDER INFORMATION
*Ordering NPI			*Ordering TIN		Ordering Provider Contact Name
Ordering Provider Name				Phone		*Fax

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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)
		(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

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part 1 to filling in ambetter prior auth form

Note the appropriate information in Same, as, Ordering, Provider Servicing, NP, I 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 CP, THC, PCS Modifier, and CP, THC, PCS area.

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You will need to put down some information within the area D, ME, Rental, Purchase Purchase, Price and Rev, EWP, AF

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