[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283855-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283855-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","ambetter-prior-authorization-fax-form-outpatient","Ambetter Prior Authorization Fax Form - Outpatient","","Ambetter outpatient prior authorization fax form for requesting additional units and submitting standard or urgent pre-service determinations within 3 calendar days (72 hours). The form collects member details, requesting provider information, and servicing provider or facility information, including identifying numbers and contact data. It requires service type selection using provided codes and mandates completion of required fields, submission of all supporting clinical information, and adherence to confidentiality and eligibility/payment disclaimer terms.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/ambetter-prior-authorization-fax-form-outpatient/283855/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/ambetter-prior-authorization-fax-form-outpatient/283855.png","ImageObject",442,249,{"name":42,"@type":43},"Melati","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-11-04","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",22,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"How fast is a standard or urgent pre-service determination completed after faxing the request?","Question",{"text":63,"@type":64},"Standard and urgent pre-service requests require determination within 3 calendar days (72 hours) after receiving the request.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What happens if required fields are incomplete on the fax form?",{"text":68,"@type":64},"Incomplete forms are rejected, so all required fields must be filled in.",{"name":70,"@type":61,"acceptedAnswer":71},"Are supporting clinical records required with the authorization request?",{"text":72,"@type":64},"Yes. Copies of all supporting clinical information are required, and lack of clinical information may result in delayed determination.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283855,1790429203,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":4},962085570644,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","OUTPATIENT  \nPrior Authorization Fax Form  \nFax to: 855-537-3447  \nRequest for additional units. Existing Authorization Units  \nStandard and Urgent Pre-Service Requests-Determination within 3 calendar days (72 hours) of receiving the request  \n* INDICATES REQUIRED FIELD  \nMEMBER INFORMATION  \nMember ID * Last Name, First  \nDate of Birth  \n(MMDDYYYY)  \nREQUESTING PROVIDER INFORMATION  \nRequesting NPI * Requesting TIN * Requesting Provider Contact Name  \n*0697*  \nRequesting Provider Name Phone Fax  \nSERVICING PROVIDER / FACILITY INFORMATION   Same as Requesting Provider  \nServicing NPI *  \n1952588329  \nServicing Provider/Facility Name City Ambulance Service  \nServicing TIN * Servicing Provider Contact Name  \n Monica C.   \nPhone  \n2815717080 ext 525  \nFax  \n3466426422  \nAUTHORIZATION REQUEST  \n| OUTPATIENT SERVICE TYPE * (Enter the Service type number in the boxes)  |  |  |\n| --- | --- | --- |\n| 412 Auditory Services\u003Cbr>422 Biopharmacy\u003Cbr>924 Chiropractic\u003Cbr>712 Cochlear Implants and Surgery\u003Cbr>Dental Anesthesia\u003Cbr>911 O􀀞ce Visit\u003Cbr>721 Other Site\u003Cbr>771 Dialysis | DME\u003Cbr>417 Rental\u003Cbr>120 Purchase $\u003Cbr>(Purchase Price)\u003Cbr>299 Drug Testing\u003Cbr>709 Genetic Testing\u003Cbr>249 Home Health\u003Cbr>290 Hyperbaric Oxygen Therapy\u003Cbr>611 Infertility Treatments\u003Cbr>211 OB Ultrasound(s)\u003Cbr>| 497 O􀀞ce Visit/Specialty Consult\u003Cbr>210 Orthotics\u003Cbr>927 Outpatient Hospice\u003Cbr>794 Outpatient Services\u003Cbr>171 Outpatient Surgery\u003Cbr>202 Pain Management\u003Cbr>147 Prosthetics\u003Cbr>201 Sleep Study\u003Cbr>724 Transportation |\n\nALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED.  \nCOPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION.  \nDisclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered bene t and medically necessary with prior authorization as per Ambetter policy and procedures.  \nCon dentiality: The information contained in this transmission is con dential and may be protected under the Health Insurance Portability and Accountability Act of  \n1996. 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.  \nRev. 01 12 2016 TX-PAF-0697","cbCaidhwItOWIiXL","https://ap.wps.com/l/cbCaidhwItOWIiXL","pdf",613063,"English","# Member information\n# Requesting provider information\n# Servicing provider or facility information\n# Authorization request\n## Outpatient service type","[{\"question\":\"How fast is a standard or urgent pre-service determination completed after faxing the request?\",\"answer\":\"Standard and urgent pre-service requests require determination within 3 calendar days (72 hours) after receiving the request.\"},{\"question\":\"What happens if required fields are incomplete on the fax form?\",\"answer\":\"Incomplete forms are rejected, so all required fields must be filled in.\"},{\"question\":\"Are supporting clinical records required with the authorization request?\",\"answer\":\"Yes. Copies of all supporting clinical information are required, and lack of clinical information may result in delayed determination.\"}]","Ambetter Prior Authorization Fax Form - Outpatient | PDF",1789620922]