[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288084-105":53,"doc-detail-288084-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","outpatient-authorization-form-rev-09-03-2020","Outpatient Authorization Form - Rev. 09 03 2020","","Outpatient Authorization Form used to request additional outpatient service units under standard or urgent timelines. The form collects member identification, ordering provider and servicing provider/facility details, primary and additional CPT/HCPCS procedure codes with modifiers, admission/start and discharge/end dates, diagnosis code (ICD-10), and total units. It specifies how to enter outpatient service type numbers, highlights required fields and supporting clinical documentation, and includes guidance on medical necessity, urgency signature requirements, and important disclaimers about prior authorization and payment eligibility.",{"@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-rev-09-03-2020/288084/",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-rev-09-03-2020/288084.png","ImageObject",442,249,{"name":88,"@type":89},"Violet","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required to submit an outpatient authorization request?","Question",{"text":108,"@type":109},"The form requires member information, ordering provider and servicing provider/facility details, procedure codes (CPT/HCPCS) with modifiers, start/admission and end/discharge dates, diagnosis code (ICD-10), and total units/visits/days.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How are standard and urgent requests handled?",{"text":113,"@type":109},"Standard requests require determination within 5 calendar days after receiving all necessary information. Urgent requests require determination within 48 hours and must be signed by the requesting physician.",{"name":115,"@type":106,"acceptedAnswer":116},"Does authorization guarantee payment?",{"text":117,"@type":109},"No. The form states that authorization is not a guarantee of payment and services must be eligible, covered, and medically necessary with prior authorization according to policy and procedures.","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},288084,1789633090,{"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":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":4},4398048950312,"https://ap-avatar.wpscdn.com/avatar/400002538284de19e3c?_k=1778320343897328908","OUTPATIENT AUTHORIZATION FORM  \nComplete and Fax to: Medical 855-218-0592 Behavioral 833-286-1086 Transplant 833-552-1001  \nRequest for additional units. Existing Authorization Units  \nStandard requests- Determination within 5 calendar days of receiving all necessary information.  \nI certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within Urgent requests- 48 hours to avoid complications and unnecessary suffering or severe pain.  \nURGENT REQUESTS MUST BE SIGNED BY THE  \n* INDICATES REQUIRED FIELD  X REQUESTING PHYSICIAN TO RECEIVE PRIORITY.   \n*Date of Birth  \nMEMBER INFORMATION  \n*Member ID  \nORDERING PROVIDER INFORMATION  \n*Ordering NPI *Ordering TIN  \nOrdering Provider Name  \nLast Name, First  \n(MMDDYYYY)  \nOrdering Provider Contact Name  \nPhone *Fax  \n*0687*  \nSERVICING PROVIDER / FACILITY INFORMATION  \n Same as Ordering 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 (Enter the Service type number in the boxes) |  |  |\n| --- | --- | --- |\n| 412 Auditory\u003Cbr>712 Cochlear Implants & Surgery\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>997 Office Visit/Consult\u003Cbr>794 Outpatient Services\u003Cbr>299 Drug Testing | 202 Pain Management\u003Cbr>171 Outpatient Surgery\u003Cbr>650 Radiation Therapy\u003Cbr>201 Sleep Study\u003Cbr>993 Transplant Evaluation\u003Cbr>209 Transplant Surgery\u003Cbr>724 Transportation\u003Cbr>DME\u003Cbr>417 Rental\u003Cbr>120 Purchase\u003Cbr>(Purchase Price) | Behavioral Health-please send all supporting forms and medical\u003Cbr>records as necessary based on service\u003Cbr>515 Electroconvulsive Therapy\u003Cbr>516 Intensive Outpatient Therapy\u003Cbr>518 Mental Health /Chemical Dependency Observation\u003Cbr>521 Psychological Testing\u003Cbr>512 Community Based Services-circle appropriate option: ABA Services TMS\u003Cbr>510 Medical Management\u003Cbr>519 Outpatient Therapy\u003Cbr>522 Psychiatric Evaluation\u003Cbr>514 Day Treatment-Partial Hospitalization Program |\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. 09 03 2020 EW-PAF-0687","cbCaiutKydxxrsBW","https://ap.wps.com/l/cbCaiutKydxxrsBW","pdf",693526,"English","# Member Information\n# Ordering Provider Information\n# Servicing Provider / Facility Information\n# Authorization Request\n## Procedure Codes and Dates\n## Diagnosis Code and Total Units\n# Outpatient Service Type","[{\"question\":\"What information is required to submit an outpatient authorization request?\",\"answer\":\"The form requires member information, ordering provider and servicing provider/facility details, procedure codes (CPT/HCPCS) with modifiers, start/admission and end/discharge dates, diagnosis code (ICD-10), and total units/visits/days.\"},{\"question\":\"How are standard and urgent requests handled?\",\"answer\":\"Standard requests require determination within 5 calendar days after receiving all necessary information. Urgent requests require determination within 48 hours and must be signed by the requesting physician.\"},{\"question\":\"Does authorization guarantee payment?\",\"answer\":\"No. The form states that authorization is not a guarantee of payment and services must be eligible, covered, and medically necessary with prior authorization according to policy and procedures.\"}]","Outpatient Authorization Form - Rev. 09 03 2020 | PDF"]