In the landscape of medical and health services, the Precertification form serves as a crucial bridge between healthcare providers and insurance coverage, ensuring that the necessary treatments received by patients align with their insurance benefits. By requiring a thorough account of the patient's information, including Amerigroup ID, Medicaid identification, and a comprehensive description of the requested service, the Precertification form meticulously verifies the eligibility and coverage before any service is rendered. This verification process extends to a wide range of services such as durable medical equipment (DME), various therapies including occupational, physical, and speech therapy, home health, hospice, pharmacy, and even dental surgery. Moreover, it encapsulates a detailed request for service authorization, encompassing requested dates, diagnosis codes, procedure codes, and the specifics of the servicing provider, which is essential for facilitating effective communication between healthcare and insurance providers. The form also intricately details instructions for maternity care notifications and surgery requests, reinforcing its role as an indispensable tool in the preemptive clarification of coverage. As such, the Precertification form not only navigates the challenges of healthcare billing and insurance claims but also underscores the commitment to patient care through the streamlining of administrative processes. Embedded within the form's structure is a reminder of the conditional nature of precertification; while it's a critical step in the authorization process, it does not guarantee payment, echoing the complex interplay between clinical necessity, member eligibility, and policy coverage. Clearly, this form is an essential component in the delivery of healthcare services, designed to mitigate financial risks for both providers and patients while ensuring that necessary medical services are promptly and efficiently authorized and administered.
| Question | Answer |
|---|---|
| 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 |