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Collects member information, requesting provider details (NPI, TIN, contact information), and servicing provider/facility information. Requires identification of the outpatient service type using designated service codes and submission of all required clinical supporting documentation. Includes determination timing guidance for standard and urgent pre-service requests and states that authorization is not a guarantee of payment, with eligibility and medical-necessity requirements. 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Existing Authorization  Units   Standard 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 * Servicing TIN * Servicing Provider Contact Name  \nServicing Provider/Facility Name Phone Fax  \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 Office 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 Office 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 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. 01 12 2016 TX-PAF-0697","cbCairpf7dNjwEMQ","https://ap.wps.com/l/cbCairpf7dNjwEMQ","pdf",767902,"English","# Member Information\n# Requesting Provider Information\n# Servicing Provider / Facility Information\n# Authorization Request\n## Outpatient Service Type Codes\n# Required Submissions and Disclaimers","[{\"question\":\"What is the purpose of this outpatient prior authorization fax form?\",\"answer\":\"It is used to request additional units for outpatient services and supports standard or urgent pre-service authorization determination.\"},{\"question\":\"What information must be completed to avoid rejection?\",\"answer\":\"All required fields must be filled in, and supporting clinical information must be copied and submitted with the form.\"},{\"question\":\"Does receiving authorization guarantee payment?\",\"answer\":\"No. Authorization is not a guarantee of payment, and services must be covered and medically necessary with member eligibility at the time of service.\"}]","OUTPATIENT Prior Authorization Fax Form - Rev. 01 - 12 2016 - TX-PAF-0697 | PDF",1789633080]