Ambetter Prior Authorization Form 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?Yes
Fillable fields30
Avg. time to fill out6 min 19 sec
Other namesambetter prior authorization form texas, ambetter prior authorization, ambetter prior authorization form medication, ambetter prior authorization phone number

Form Preview Example

TX-PAF-0588

OUTPATIENT

 

Fax to: 855-537-3447

 

 

Prior Authorization Fax Form

 

Request for additional units. Existing Authorization

Units

ICD-9 ICD-10

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

 

 

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 sufering or severe pain.

X

URGENT REQUESTS MUST BE SIGNED BY THE

REQUESTING PHYSICIAN TO RECEIVE PRIORITY.

*INDICATES REQUIRED FIELD

 

 

 

 

Date of Birth

MEMBER INFORMATION

 

Member ID *

 

Last Name, First

(MMDDYYYY)

 

 

REQUESTING PROVIDER INFORMATION

 

 

Requesting NPI *

Requesting TIN *

 

Requesting Provider Contact Name

*0588*

Requesting Provider NamePhoneFax

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

Total Units/Visits/Days

(CPT/HCPCS)

(Modiier)

(MMDDYYYY)

 

 

OUTPATIENT SERVICE TYPE *

(Fill in the square with an X)

 

Parenteral Feedings

 

 

 

 

Air Ambulance Fixed Wing

Genetic Testing

Oice Visit

 

 

 

 

 

Prosthetics

Biopharmacy

 

Home Health

 

Oice Visit

 

 

 

 

 

 

 

Quantitative Urine Drug Screen

Chiropractic

 

Hospice Outpatient

 

Other Site

 

 

 

 

 

 

 

Sleep Study

Cochlear Implants

 

Observation Stay

Orthotics

and Surgery

 

 

Home

 

 

 

DME

 

OB Ultrasound

Outpatient Services

 

 

Other Site

Enteral Feedings

 

 

Pain Management

 

 

 

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

Conidentiality: 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.

How to Edit Ambetter Out Patient

Filling out ambetter authorization form is simple. Our experts designed our PDF editor to make it simple to operate and allow you to fill in any form online. Here are a couple steps you'll want to go through:

Step 1: Hit the orange button "Get Form Here" on the page.

Step 2: Right now, you may edit the ambetter authorization form. The multifunctional toolbar makes it possible to insert, eliminate, adjust, highlight, and also undertake other sorts of commands to the words and phrases and areas inside the document.

You'll have to enter the next information so that you prepare the template:

ambetter retro authorization form spaces to fill out

Provide the necessary details in the space Servicing NPI, Servicing TIN*, Servicing Provider Contact Name, Servicing Provider/Facility Name, Phone, Fax, AUTHORIZATION REQUEST Primary, Start Date OR Admission Date *, Diagnosis Code *, (CPT/HCPCS), (Modiier), (MMDDYYYY), (ICD-9), Additional Procedure Code, End Date OR Discharge Date, Total Units/Visits/Days, (CPT/HCPCS), (Modiier), (MMDDYYYY), OUTPATIENT SERVICE TYPE * (Fill in, and Parenteral Feedings.

Filling out ambetter retro authorization form part 2

Step 3: Choose the "Done" button. Now you may transfer your PDF file to your device. As well as that, you'll be able to forward it via electronic mail.

Step 4: It's going to be better to maintain duplicates of your file. You can rest assured that we will not display or read your data.

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 .