Txpec Form PDF Details

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QuestionAnswer
Form NameTxpec Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesform precertification request amerigroup, txpec, precertification request get, contact authorization amerigroup get

Form Preview Example

Precertification request

Amerigroup prior authorization: 1-800-454-3730 Fax: 1-800-964-3627

To prevent delay in processing your request, please fill out form in its entirety with all applicable information.

Today’s date:

Provider return fax:

 

Member information

 

 

First name:

Last name:

Amerigroup member ID:

 

 

 

Address:

 

City, State ZIP code:

 

 

 

DOB:

Contact Phone:

 

 

 

 

Additional member information:

 

 

Referring provider

Participating

Nonparticipating

Full name:

NPI:

 

 

 

 

 

 

 

 

 

Provider ID:

 

Tax ID number (TIN):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office contact name:

 

 

 

 

 

 

 

 

 

Office phone:

 

Office fax:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

City, State ZIP code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specialty:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Servicing provider

 

 

 

Participating

 

 

 

Nonparticipating

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI:

 

 

 

 

 

 

 

 

 

Provider ID:

 

TIN:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office contact name:

 

 

 

 

 

 

 

 

 

Office phone:

 

Office fax:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

City, State ZIP code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specialty:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Servicing facility

 

 

 

Participating

 

 

 

Nonparticipating

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI:

 

 

 

 

 

 

 

 

 

Provider ID:

 

TIN:

 

Facility contact name:

 

 

 

 

 

 

 

Facility phone:

 

Facility fax:

Address:

 

 

 

 

 

 

 

 

 

City, State ZIP code:

 

 

 

 

Requested service (for type of service, check all that apply)

Date/date range of service:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ICD-10 code(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CPT code(s) (include requested units):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of service:

☐ Outpatient

☐ Planned inpatient

☐ Emergent inpatient

 

☐ Skilled nursing facility

☐ Long-term services & supports/long-term care

☐ Home health

 

 

 

 

☐ Durable medical equipment

 

 

☐ Diagnostic study

☐ Hospice

☐ Office visit

☐ Personal care services

☐ Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of service: ☐ Hospital

 

 

☐ Ambulatory surgery center

☐ Office

☐ Home

☐ Independent lab

 

☐ Nursing facility

☐ Other:

 

 

 

 

 

 

 

 

 

 

 

 

Additional information:

Please submit all appropriate clinical information, provider contact information and any other required documents with this form to support your request. If this is a request for extension or modification of an existing authorization from Amerigroup, please provide the authorization number with your submission.

Emergent – use for ALL nonelective INPATIENT admissions only, when provider indicates that the admission was urgent, emergent or expedited (for admission on same day).

Urgent – use for OUTPATIENT services only, when provider indicates that the service is urgent, emergent or expedited.

Disclaimer: Authorization is based on verification of member eligibility and benefit coverage at the time of service and is subject to Amerigroup

Community Care claims payment policy and procedures.

 

TXPEC-1545-15

February 2016

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