Do you need to submit a precertification for medical services? The process can be complicated, with paperwork that must be filled out correctly in order to ensure that the appropriate insurance coverage is available. To make the process easier, many healthcare providers provide a template form for precertification requests. This document serves as an efficient way of gathering the details necessary to start and complete the precertification process accurately. In this blog post, we'll discuss what information is typically included on the template form, along with any additional steps necessary to successfully complete your request. So if you're ready to get started, read on!
Question | Answer |
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Form Name | Precertification Template Form |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | precertification form example, amerigroup prior authorization form iowa, amerigroup precertification request form get, webpks |
Precertification request Phone:
Today’s date: |
Return fax for prior authorization: |
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Please attach clinical information to support medical necessity |
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Disclaimer: Authorization is based on verification of member eligibility and benefit coverage at the time of service and is subject to
Amerigroup Kansas, Inc. claims payment policies and procedures
Member information
Name (Last, first): |
Amerigroup ID #: |
Date of birth: |
Address: |
City, State ZIP code: |
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State Medicaid ID #: |
Other insurance/worker’s comp: |
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Service/prior authorization request - if requesting durable medical equipment (DME), please include modifier(s), cost and pricing
information.
Service type (check all that apply): DME Occupational therapy Physical therapy Speech therapy Home health Hospice
Pharmacy Dental surgery Other (please describe)
Place of service: Office Home
Requested dates of service:
CPT codes:
# Of units/visits and frequency requested:
Servicing provider
Provider name: (Last, First, Provider specialty)
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Amerigroup provider/group ID #: |
Office contact name: |
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Network status: Par |
Phone #: |
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If OON, will you accept KS Medicaid rates? yes no |
Fax #: |
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Tax ID #: |
Address: |
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NPI #: |
City, State ZIP code: |
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Have you seen this member before? Yes No |
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Ordering/referring provider |
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Provider name: (Last, First) |
Office contact name: |
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Amerigroup provider/group ID #: |
Phone #: |
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Tax ID #: |
Fax #: |
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NPI #: |
Address: |
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Network status: Par OON |
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Facility |
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Facility name: |
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Amerigroup provider/facility ID #: |
Office contact name: |
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Network status: Par OON |
Phone #: |
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If OON, will you accept KS Medicaid rates? yes no |
Fax #: |
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Tax ID #: |
Address: |
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NPI #: |
City, State ZIP code: |
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Provider name: (Last, First, Provider specialty) |
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Maternity care |
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For initial notification of pregnancy, please use the Maternity Notification Form found under Maternal Child Program at providers.amerigroup.com.
For all other services related to pregnancy, please use this form (e.g., a second ultrasound, fetal
Surgery request
Surgeon’s full name: (Last, First)
Facility (please fill out facility and service information above)
Inpatient
This referral is valid only for services authorized by this form. Only completed referrals will be processed. If the 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 confirm precertification is required for this service, use the Precertification Lookup tool on the provider
February 2016 |