The Amerigroup Provider Return form plays a pivotal role in the healthcare process for both providers and members, serving as a critical communication tool to request various medical services. This comprehensive form facilitates authorization requests, requiring detailed member information, including the Amerigroup number, date of birth, and Medicaid details, among others, ensuring patient eligibility is verified prior to service provision. It meticulously gathers referring provider data, including Medicaid and Amerigroup numbers, underscoring the importance of clarity in the healthcare provider’s details. The form accommodates a diverse range of services from specialist consultations to surgeries and diagnostic studies, each section tailored to capture specific information such as diagnosis codes, reasons for referral, and the nature of previous treatments. Notably, the form addresses maternity care, specifying a different procedure for initial pregnancy notifications, while also making provisions for other pregnancy-related services. The requirement for attaching clinical information to support the medical necessity of the requested service underlines the form’s role in maintaining the integrity of healthcare service requests. It concludes with an area for Amerigroup to complete, indicating approval dates and reference numbers, thereby finalizing the authorization process. The instruction for clear printing to avoid delays emphasizes the form’s essential function in the expedient processing of necessary healthcare services. However, it also serves as a reminder that certification of a request does not guarantee payment, as claims are subject to eligibility and contractual constraints, highlighting the complexity of healthcare service authorization and reimbursement.
| Question | Answer |
|---|---|
| Form Name | Amerigroup Provider Return Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | amerigroup provider sheet, AMERIGROUP, Outpt, Inpt |
AUTHORIZATION REQUEST
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Phone: |
Fax: |
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** To avoid delay, please print clearly ** |
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TODAY’S DATE: |
PROVIDER RETURN FAX #: |
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MEMBER INFORMATION (Please verify eligibility prior to rendering service) |
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NAME:(Last Name, First Name) |
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AMERIGROUP#: |
DOB: |
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ADDRESS: |
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CITY,STATE,ZIP: |
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MEDICAID#: |
OTHERINSURANCE/WORKER’SCOMP: |
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REFERRING PROVIDER INFORMATION |
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NAME: |
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OFFICECONTACTNAME: |
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MEDICAIDPROVIDER#: |
AMERIGROUP#: |
GROUPPRACTICE#: |
NPI#: |
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PHONE#: |
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❑ Check the box where the OTHERPHONE#: |
❑ Fax back |
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PHONE#: |
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❑ referral should be faxed back OTHERPHONE#: |
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SPECIALIST CONSULT
CONSULTANT:(Last Name, First Name, Provider Specialty)
AMERIGROUPPROVIDER#: NPI#: PHONE#: FAX#:
ADDRESS:CITY,STATE,ZIP:
PMH/PREVIOUSSTUDIES/TREATMENT:
#OFVISITSREQUIRED:
MATERNITY CARE
For initial notification of pregnancy, please use the Maternity Notification form.
For all other services related to pregnancy, please use this form (e.g. ultrasound, fetal
DIAGNOSTIC STUDY
FACILITYNAME:DOS:
DIAGNOSIS/REASONFORREFERRAL:
PMH/PREVIOUSSTUDIES/TREATMENTS:
SURGERY REQUEST
SURGEON’SFULLNAME:(Last Name, First Name) |
DOS: |
❑Inpt ❑Outpt ❑Ext Stay |
FACILITYNAME:
DIAGNOSIS/REASONFORSURGERY:
PMH/PREVIOUSSTUDIES/TREATMENTS:
OTHER - Clinical Information Needed
❑DME ❑ Home Health ❑ Hospice ❑ Other
REFERREDTOPROVIDER:(Last Name, First Name) |
AMERIGROUPPROVIDER#: |
NPI#: |
DIAGNOSIS/REASONFORREFERRAL:
PMH/PREVIOUSSTUDIES/TREATMENTS:
** PLEASE ATTACH CLINICAL INFORMATION TO SUPPORT MEDICAL NECESSITY **
This referral is valid only for services authorized by this form. Only completed referrals will be processed. If hte consultant/provider recommends another service or surgery, additional authorization is required. Certification does not guarantee that benefits will be paid. Payment of claims is subject to eligibility, contractual limitations, provisions, and exclusions.
To be completed by AMERIGROUP: DATEAPPROVED:
DATESPAN:REFERENCE#: INITIALSOFAPPROVER: