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Collects member details, request dates, requesting and servicing provider identifiers (NPI, TIN), and facility contact information. Captures primary and additional outpatient procedure codes (CPT/HCPCS) with modifiers, diagnosis code (ICD-10), and total units. Includes outpatient service type and behavioral health options, with start/end admission or discharge dates and total utilization fields. Requires all marked fields and supporting clinical documentation.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/outpatient-authorization-form-complete-and-fax-request-for-additional-units/288822/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/outpatient-authorization-form-complete-and-fax-request-for-additional-units/288822.png","ImageObject",442,249,{"name":88,"@type":89},"Lute","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-12","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information must be provided on this outpatient authorization form?","Question",{"text":108,"@type":109},"The form requests member information, requesting and servicing provider identifiers (NPI and TIN), procedure codes with modifiers, diagnosis code (ICD-10), start/end dates, and total units/visits/days.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What is required for processing and how is incomplete submission handled?",{"text":113,"@type":109},"All required fields must be completed; incomplete forms are rejected. Copies of all supporting clinical information are required, and lack of clinical details may delay determination.",{"name":115,"@type":106,"acceptedAnswer":116},"Does an approved authorization guarantee payment?",{"text":117,"@type":109},"No. Authorization is not a guarantee of payment, and the member must be eligible when services are rendered and the services must be a covered, medically necessary benefit under prior authorization rules.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288822,1790052916,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":135,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},137454149569,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","OUTPATIENT AUTHORIZATION FORM  \nComplete and Fax to: 1-855-690-5433  \nRequest for additional units. Existing Authorization Units  \nStandard requests-Determination within 36 hours, which shall include one working day, or up to 14 days, if necessary, to receive all pertinent clinical information.  \nPlease call 1-855-650-3789 . *Urgent requests are made when the member or his/her physician believes that waiting for a decision Urgent requests-under the standard timeframe could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy.  \n* INDICATES REQUIRED FIELD  *Date of Birth   \nMEMBER INFORMATION  \n*Member ID  \nLast Name, First  \n(MMDDYYYY)  \nREQUESTING PROVIDER INFORMATION  \n*Requesting NPI *Requesting TIN Requesting Provider Contact Name  \n*1599*  \nRequesting Provider Name Phone *Fax  \nSERVICING PROVIDER / FACILITY INFORMATION  \n~~ ~~ Same as Requesting Provider  \n*Servicing NPI *Servicing TIN Servicing Provider Contact Name  \nServicing Provider/Facility Name Phone Fax  \nAUTHORIZATION REQUEST  \n*Primary Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \n*Start Date OR Admission Date  \n(MMDDYYYY)  \nEnd Date OR Discharge Date  \n(MMDDYYYY)  \n*Diagnosis Code  \n(ICD-10)  \nTotal Units/Visits/Days  \n\n| *OUTPATIENT SERVICE TYPE\u003Cbr>412 Auditory\u003Cbr>422 Biopharmacy\u003Cbr>712 Cochlear Implants & Surgery\u003Cbr>299 Drug Testing\u003Cbr>922 Experimental and Investigational Services\u003Cbr>205 Genetic Testing & Counseling\u003Cbr>249 Home Health\u003Cbr>390 Hospice Services\u003Cbr>290 Hyperbaric Oxygen Therapy\u003Cbr>395 Infertility Diagnosis or Treatment\u003Cbr>211 OB Ultrasound | (Enter the Service type number in the boxes) |  |  |\n| --- | --- | --- | --- |\n|  | 410 Observation\u003Cbr>997 Office Visit/Consult\u003Cbr>210 Orthotics\u003Cbr>794 Outpatient Services\u003Cbr>171 Outpatient Surgery\u003Cbr>202 Pain Management\u003Cbr>147 Prosthetics\u003Cbr>201 Sleep Study\u003Cbr>993 Transplant Evaluation\u003Cbr>209 Transplant Surgery\u003Cbr>724 Transportation | Behavioral Health DME\u003Cbr>533 BH Applied Behavioral Analysis 417 Rental\u003Cbr>512 BH Community Based Services 120 Purchase\u003Cbr>515 BH Electroconvulsive Therapy\u003Cbr>516 BH Intensive Outpatient Therapy\u003Cbr>510 BH Medical Management\u003Cbr>518 BH Mental Health /Chemical Dependency Observation\u003Cbr>519 BH Outpatient Therapy\u003Cbr>530 BH PHP\u003Cbr>520 BH Professional Fees\u003Cbr>522 BH Psychiatric Evaluation\u003Cbr>521 BH Psychological Testing | (Purchase Price) |\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 benefit and medically necessary with prior authorization as per Ambetter policy and procedures.  \nConfidentiality: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.  \nRev. 02 28 2019 EQ-PAF-1599","cbCaivHWP9IFqRc5","https://ap.wps.com/l/cbCaivHWP9IFqRc5","pdf",134020,9,"English","# Authorization Request\n## Member Information\n## Requesting Provider Information\n## Servicing Provider/Facility Information\n## Authorization Request Details","[{\"question\":\"What information must be provided on this outpatient authorization form?\",\"answer\":\"The form requests member information, requesting and servicing provider identifiers (NPI and TIN), procedure codes with modifiers, diagnosis code (ICD-10), start/end dates, and total units/visits/days.\"},{\"question\":\"What is required for processing and how is incomplete submission handled?\",\"answer\":\"All required fields must be completed; incomplete forms are rejected. Copies of all supporting clinical information are required, and lack of clinical details may delay determination.\"},{\"question\":\"Does an approved authorization guarantee payment?\",\"answer\":\"No. Authorization is not a guarantee of payment, and the member must be eligible when services are rendered and the services must be a covered, medically necessary benefit under prior authorization rules.\"}]","OUTPATIENT AUTHORIZATION FORM - Complete and Fax Request for Additional Units | PDF",1789634019]