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.

You might find it useful to understand how much time you'll need to complete this ambetter out patient and just how lengthy the form is.

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

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

<![endif]>*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 prior authorization form medication 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 prior authorization form medication. 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 prior auth form

Note the appropriate information in SameasOrderingProvider, ServicingNPI, ServicingTIN, ServicingProviderContactName, ServicingProviderFacilityName, Phone, Fax, AUTHORIZATIONREQUEST, PrimaryProcedureCode, AdditionalProcedureCode, StartDateORAdmissionDate, DiagnosisCode, CPTHCPCS, Modifier, and CPTHCPCS area.

Completing ambetter prior auth form step 2

You will need to put down some information within the area DMERentalPurchase, PurchasePrice, and RevEWPAF.

part 3 to completing ambetter prior auth form

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.

Watch Ambetter Out Patient Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .