*0697*
(MMDDYYYY)
(ICD-10)
(MMDDYYYY)
(CPT/HCPCS)
(CPT/HCPCS) (Modifier)
(Modifier)
(CPT/HCPCS)
(CPT/HCPCS) (Modifier)
(Modifier)
(Purchase Price)
OUTPATIENT
Prior Authorization Fax Form
Fax to:
855-537-3447
Request for additional units. Existing Authorization Units
(MMDDYYYY)
Standard and Urgent Pre-Service Requests - Determination within 3 calendar days (72 hours) of receiving the request
*
INDICATES REQUIRED FIELD
MEMBER INFORMATION
Date of Birth
Member ID
*
Last Name, First
REQUESTING PROVIDER INFORMATION
Requesting NPI
*
Requesting TIN
*
Requesting Provider Contact Name
Requesting Provider Name
Phone
Fax
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*
Additional Procedure Code
Start Date OR
Admission Date
*
Diagnosis Code
*
Additional Procedure Code Additional Procedure Code
End Date OR Discharge Date Total Units/Visits/Days
OUTPATIENT SERVICE TYPE
*
(Enter the Service type number in the boxes)
412 Auditory Services
422 Biopharmacy
924 Chiropractic
712 Cochlear Implants and Surgery
Dental Anesthesia
911 Office Visit
721 Other Site
771 Dialysis
DME
417
Rental
120
Purchase
$
299
Drug Testing
709
Genetic Testing
249
Home Health
290
Hyperbaric Oxygen Therapy
611
Infertility Treatments
211
OB Ultrasound(s)
497 Office Visit/Specialty Consult
210 Orthotics
927 Outpatient Hospice
794 Outpatient Services
171 Outpatient Surgery
202 Pain Management
147 Prosthetics
201 Sleep Study
724 Transportation
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 benefit and medically
necessary with prior authorization as per Ambetter policy and procedures.
Confidentiality: The information contained in this transmission is confidential 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.
Rev. 01 12 2016
TX-PAF-0697
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