Inpatient Prior Authorization Form - Rev. 09 - 03 2020 - EW-PAF-0686

Sep 17, 2026

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Inpatient prior authorization form for submitting standard or urgent inpatient requests to Medical, Behavioral, or Transplant channels. Collects member details, ordering and servicing provider identifiers, procedure codes (CPT/HCPCS) with modifiers, start/admission and discharge dates, and ICD-10 diagnosis codes. Includes inpatient service type selection and specific options for behavioral health and substance use. Requires required fields to be completed, supporting clinical documents to be attached, and urgent requests to be physician-signed for priority consideration. Includes HIPAA confidentiality and non-guarantee of payment disclaimer.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Member Information

Ordering Provider Information

Servicing Provider / Facility Information

Authorization Request

Procedure and Diagnosis Codes

Inpatient Service Type

Urgent Request Requirements

Required Attachments and Disclaimers

INPATIENT PRIOR AUTHORIZATION FORM Complete and Fax to: Medical 855-218-0592 Behavioral 833-286-1086 Transplant 833-552-1001 Standard requests- Determination within 5 calendar days of receiving all necessary information. Urgent requests- I certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within 48 hours to avoid complications and unnecessary suffering or severe pain. X URGENT REQUESTS MUST BE SIGNED BY THE PHYSICIAN TO RECEIVE PRIORITY * Indicates Required Field ~~ ~~ MEMBER INFORMATION *Member ID Last Name, First *Date of Birth (MMDDYYYY) ORDERING PROVIDER INFORMATION *Ordering NPI *Ordering TIN Ordering Provider Contact Name *0686* Ordering Provider Name Phone *Fax SERVICING PROVIDER / FACILITY INFORMATION Same as Ordering Provider *Servicing NPI *Servicing TIN Servicing Provider Contact Name Servicing Provider/Facility Name AUTHORIZATION REQUEST *Primary Procedure Code (CPT/HCPCS) (Modifier) Additional Procedure Code (CPT/HCPCS) (Modifier) Phone Fax Additional Procedure Code (CPT/HCPCS) (Modifier) Additional Procedure Code (CPT/HCPCS) (Modifier) *Start Date OR Admission Date (MMDDYYYY) Discharge Date (if applicable) otherwise Length of Stay will be based on Medical Necessity (MMDDYYYY) *Diagnosis Code (ICD-10) Additional Diagnosis Code (ICD-10) | *INPATIENT SERVICE TYPE (Enter the Service type number in the boxes) | | | | --- | --- | --- | | Delivery
779 C-Section Delivery 720 Vaginal Delivery
Inpatient Rehab
427 Rehab
Transplant
992 Transplant | Miscellaneous
121 Long Term Acute Care
970 Medical
414 Premature/False Labor
402 Skilled Nursing Facility
411 Surgical
490 Boarder Baby
300 Neonate | Behavioral Health-please send all supporting forms and medical records as necessary based on service
528 Chemical Substance Abuse-circle appropriate option:
ASAM: 3.2 3.7 4.0 AND Involuntary Voluntary
532 Crisis Stabilization Unit
531 Eating Disorders
529 Psychiatric Admission-circle appropriate option: Involuntary Voluntary
536 Residential Treatment-Mental Health -circle appropriate option:
Short Term (less than 30 days) Long Term (greater than 30 days)
535 Residential Treatment-Substance Use-circle appropriate option: ASAM: 3.1 3.3 3.5 | 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.09 03 2020 EW-PAF-0686

FAQs

What is the form used for?

It is used to request prior authorization for inpatient services by submitting member, provider, procedure, and diagnosis information.

How are urgent requests handled?

Urgent requests require the member’s request to be certified as urgent and medically necessary within 48 hours, and urgent requests must be signed by the physician to receive priority.

What happens if required fields or supporting clinical information are missing?

Incomplete forms will be rejected. Missing supporting clinical information may result in delayed determination.

Sep 17, 2026

Upload by Adam