[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288078-105":53,"doc-detail-288078-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-prior-authorization-fax-form-urgent-requests","OUTPATIENT Prior Authorization Fax Form - Urgent Requests","","Outpatient Prior Authorization Fax Form used to request additional units under an existing authorization. Includes member details, requesting and servicing provider/facility information, and an authorization request section that lists outpatient service types by number for selection. Standard requests are determined within 15 calendar days after receiving all necessary information; urgent requests must be signed by the requesting physician and certified as medically necessary within 72 hours. Requires all mandatory fields and supporting clinical information; outlines payment not guaranteed and confidentiality notices.",{"@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-prior-authorization-fax-form-urgent-requests/288078/",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-prior-authorization-fax-form-urgent-requests/288078.png","ImageObject",442,249,{"name":88,"@type":89},"Hazel","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-25","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":73},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required to submit the outpatient prior authorization fax form?","Question",{"text":108,"@type":109},"The form requires mandatory member details, requesting provider information, servicing provider/facility information, and the outpatient service type selection. All required fields must be completed, and supporting clinical information copies must be included.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How long does it take to determine a standard prior authorization request?",{"text":113,"@type":109},"Standard request determination occurs within 15 calendar days of receiving all necessary information.",{"name":115,"@type":106,"acceptedAnswer":116},"What makes a request urgent and how should it be handled?",{"text":117,"@type":109},"An urgent request must be certified as medically necessary to treat an injury, illness, or condition within 72 hours to avoid complications. Urgent requests must be signed by the requesting physician to receive priority.","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},288078,1790297002,{"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},137441390410,"https://ap-avatar.wpscdn.com/avatar/2000252f4ab5702993?_k=1776741390130283984","OUTPATIENT  \nPrior Authorization Fax Form  \nRequest for additional units. Existing Authorization Units   \nStandard Request-Determination within 15 calendar days of receiving all necessary information.  \nFax to: 855-685-6508  \nUrgent Request- I certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within 72 hours to avoid complications and unnecessary suffering or severe pain.  \nX  \nURGENT REQUESTS MUST BE SIGNED BY THE REQUESTING PHYSICIAN TO RECEIVE PRIORITY.  \n* INDICATES REQUIRED FIELD  Date of Birth   \nMEMBER INFORMATION   \nMember ID * Last Name, First (MMDDYYYY)  \nREQUESTING PROVIDER INFORMATION  \n*0689*  \nRequesting NPI * Requesting TIN * Requesting Provider Contact Name  \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| 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\u003Cbr>299 Drug Testing | DME\u003Cbr>417 Rental\u003Cbr>120 Purchase $\u003Cbr>(Purchase Price)\u003Cbr>709 Genetic Testing\u003Cbr>249 Home Health\u003Cbr>600 Home Infusion\u003Cbr>290 Hyperbaric Oxygen Therapy\u003Cbr>611 Infertility Treatments\u003Cbr>240 Inpatient Hospice\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 | 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.  \nIf 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 Rev. 01 12 2016  \ndestroy this document. GA-PAF-0689","cbCaisqLpCplLeGv","https://ap.wps.com/l/cbCaisqLpCplLeGv","pdf",810733,6,"English","# Member information\n# Requesting provider information\n# Servicing provider/facility information\n# Authorization request\n# Submission requirements and notices","[{\"question\":\"What information is required to submit the outpatient prior authorization fax form?\",\"answer\":\"The form requires mandatory member details, requesting provider information, servicing provider/facility information, and the outpatient service type selection. All required fields must be completed, and supporting clinical information copies must be included.\"},{\"question\":\"How long does it take to determine a standard prior authorization request?\",\"answer\":\"Standard request determination occurs within 15 calendar days of receiving all necessary information.\"},{\"question\":\"What makes a request urgent and how should it be handled?\",\"answer\":\"An urgent request must be certified as medically necessary to treat an injury, illness, or condition within 72 hours to avoid complications. Urgent requests must be signed by the requesting physician to receive priority.\"}]","OUTPATIENT Prior Authorization Fax Form - Urgent Requests | PDF",1789633085]