[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283873-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283873-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","outpatient-medicare-authorization-form-expedited-and-standard-requests","OUTPATIENT MEDICARE AUTHORIZATION FORM - Expedited and Standard Requests","","Outpatient Medicare authorization form for requesting prior approval for covered outpatient services under a health plan. The form collects member details, requesting provider and servicing provider/facility identifiers, and authorization request data including procedure codes (CPT/HCPCS), modifiers, diagnosis code (ICD-10), service start/end or admission/discharge dates, and total units/visits/days. It specifies expedited versus standard request channels and timing rules, lists required outpatient service types, and includes compliance notes on completeness, supporting clinical documentation, eligibility, payment disclaimer, and confidentiality.",{"@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/outpatient-medicare-authorization-form-expedited-and-standard-requests/283873/",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/outpatient-medicare-authorization-form-expedited-and-standard-requests/283873.png","ImageObject",442,249,{"name":42,"@type":43},"Stanford","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-29","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 are expedited and standard requests submitted and what are the timing expectations?","Question",{"text":63,"@type":64},"Expedited requests require a call to 1-800-218-7508, while standard requests require completing the form and faxing to 1-877-808-9368. Determination for standard requests is made as expeditiously as the enrollee’s health requires, but no later than 14 calendar days after receipt of the request.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What information must be provided for the member and providers?",{"text":68,"@type":64},"The form requires member date of birth and member ID, including last name and first name, plus requesting provider details (NPI, TIN, contact name, name, phone, and fax) and servicing provider/facility details (same categories).",{"name":70,"@type":61,"acceptedAnswer":71},"Which clinical and authorization details are needed to complete the authorization request?",{"text":72,"@type":64},"The request section requires primary procedure code (CPT/HCPCS) and any modifiers, optional additional procedure code and modifier, diagnosis code (ICD-10), start date or admission date (MMDDYYYY), end date or discharge date, and total units/visits/days. Supporting clinical information copies must accompany the form.","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},283873,1790448725,{"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},2336477552062,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","OUTPATIENT MEDICARE AUTHORIZATION FORM  \nExpedited requests: Call 1-800-218-7508  \nStandard Requests: Fax 1-877-808-9368 Behavioral Health Requests/Medical Records: Fax 1-855-772-7079  \nRequest for additional units. Existing Authorization Units  \nFor Standard requests, complete this form and FAX to 1-877-808-9368. Determination made as expeditiously as the enrollee’s health condition requires, but no later than 14 calendar days after receipt of request.  \nFor Expedited requests, please CALL 1-800-218-7508. Expedited requests are made when the enrollee or his/her physician believes that waiting for a decision under the  \nstandard timeframe could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy.  \n* INDICATES REQUIRED FIELD    \nDate of Birth*  \nMEMBER INFORMATION  \nMember ID* Last Name, First (MMDDYYYY)  \nREQUESTING PROVIDER INFORMATION  \nRequesting NPI* Requesting TIN* Requesting Provider Contact Name  \n*0769*  \nRequesting Provider Name Phone Fax*  \nSERVICING PROVIDER / FACILITY INFORMATION  \n Same as Requesting Provider  \nServicing NPI* Servicing TIN* Servicing Provider Contact Name  \nServicing Provider/Facility Name Phone Fax  \nAUTHORIZATION REQUEST  \nPrimary Procedure Code* Additional Procedure Code Start Date OR Admission Date* Diagnosis Code*  \n(CPT/HCPCS) (Modifier) (CPT/HCPCS) (Modifier) (MMDDYYYY) (ICD-10)  \nAdditional Procedure Code Additional Procedure Code End Date OR Discharge Date Total Units/Visits/Days  \n(CPT/HCPCS) (Modifier) (CPT/HCPCS) (Modifier) (MMDDYYYY)  \n\n| OUTPATIENT SERVICE TYPE* (Enter the Service type number in the boxes) |  |  |  |\n| --- | --- | --- | --- |\n| 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>225 Home Meals\u003Cbr>290 Hyperbaric Oxygen Therapy\u003Cbr>395 Infertility Diagnosis or Treatment\u003Cbr>729 Neuropsychological Testing\u003Cbr>410 Observation\u003Cbr>997 Office Visit/Consult\u003Cbr>794 Outpatient Services | 171 Outpatient Surgery\u003Cbr>202 Pain Management\u003Cbr>650 Radiation Therapy\u003Cbr>201 Sleep Study\u003Cbr>212 Therapy Evaluation\u003Cbr>790 Occupational Therapy\u003Cbr>101 Physical Therapy\u003Cbr>701 Speech Therapy\u003Cbr>993 Transplant Evaluation\u003Cbr>209 Transplant Surgery\u003Cbr>724 Transportation | Behavioral Health\u003Cbr>510 BH Medical Management\u003Cbr>530 BH PHP\u003Cbr>512 BH Community Based Services\u003Cbr>513 BH Crisis Psychotherapy\u003Cbr>514 BH Day Treatment\u003Cbr>515 BH Electroconvulsive Therapy\u003Cbr>518 BH Mental Health /Chemical Dependency Observation\u003Cbr>519 BH Outpatient Therapy\u003Cbr>520 BH Professional Fees\u003Cbr>521 BH Psychological Testing\u003Cbr>522 BH Psychiatric Evaluation | DME\u003Cbr>417 Rental\u003Cbr>120 Purchase\u003Cbr>(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 Health Plan Benefit and medically necessary with prior authorization as per Plan 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. 10 24 2019 MT-PAF-0769","cbCaiecttzCgHAco","https://ap.wps.com/l/cbCaiecttzCgHAco","pdf",752927,"English","# Outpatient Medicare Authorization Request\n## Request Timing: Expedited vs Standard\n## Member and Provider Information\n## Authorization Request Fields\n## Outpatient Service Type Codes\n## Requirements and Disclaimers","[{\"question\":\"How are expedited and standard requests submitted and what are the timing expectations?\",\"answer\":\"Expedited requests require a call to 1-800-218-7508, while standard requests require completing the form and faxing to 1-877-808-9368. Determination for standard requests is made as expeditiously as the enrollee’s health requires, but no later than 14 calendar days after receipt of the request.\"},{\"question\":\"What information must be provided for the member and providers?\",\"answer\":\"The form requires member date of birth and member ID, including last name and first name, plus requesting provider details (NPI, TIN, contact name, name, phone, and fax) and servicing provider/facility details (same categories).\"},{\"question\":\"Which clinical and authorization details are needed to complete the authorization request?\",\"answer\":\"The request section requires primary procedure code (CPT/HCPCS) and any modifiers, optional additional procedure code and modifier, diagnosis code (ICD-10), start date or admission date (MMDDYYYY), end date or discharge date, and total units/visits/days. Supporting clinical information copies must accompany the form.\"}]","OUTPATIENT MEDICARE AUTHORIZATION FORM - Expedited and Standard Requests | PDF",1789621196]