[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283860-105":3,"detail-sidebar-cat-1-en-105":85,"doc-detail-283860-en":130},{"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":78,"head_meta":80,"extra_data":82,"updated_unix":84},105,"en","outpatient-prior-authorization-fax-form-ver12","Outpatient Prior Authorization Fax Form - Ver12","","Outpatient prior authorization fax form for requesting additional covered units of medical services. Includes sections to collect member identification, requesting provider details, servicing provider or facility information, and an authorization request specifying the outpatient service type. Provides guidance for standard and urgent determination timeframes, requires required fields to be completed to avoid rejection, and notes that authorization does not guarantee payment. 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Existing Authorization  \nUnits  \nStandard Request-Determination within 15 calendar days of receiving all necessary information.  \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 ~~ ~~  \nDate of Birth  \nMEMBER INFORMATION   \nMember ID * Last Name, First (MMDDYYYY)  \nREQUESTING PROVIDER INFORMATION  \n*0699*  \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) |  | \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| --- | --- | --- |\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>290 Hyperbaric Oxygen Therapy\u003Cbr>240 Inpatient Hospice\u003Cbr>611 Infertility Treatments\u003Cbr>211 OB Ultrasound(s)\u003Cbr>|  |\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. 12 07 2015  \ndestroy this document. FL-PAF-0699","cbCaib9pmRoMabO0","https://ap.wps.com/l/cbCaib9pmRoMabO0","pdf",820313,"English","# Outpatient Prior Authorization Fax Form\n## Member Information\n## Requesting Provider Information\n## Servicing Provider / Facility Information\n## Authorization Request\n## Notices and Disclaimers","[{\"question\":\"What is the purpose of this outpatient prior authorization fax form?\",\"answer\":\"It is used to request prior authorization for additional units for outpatient services and to submit required authorization details by fax.\"},{\"question\":\"What information must be completed to avoid rejection?\",\"answer\":\"All required fields must be filled in, and copies of all supporting clinical information must be included; incomplete forms will be rejected.\"},{\"question\":\"How do standard and urgent requests differ?\",\"answer\":\"Standard requests follow determination within 15 calendar days after receiving all necessary information, while urgent requests must be medically necessary and signed by the requesting physician to receive priority within 72 hours.\"},{\"question\":\"Does prior authorization guarantee payment?\",\"answer\":\"No. Authorization is not a guarantee of payment, and the member must be eligible at the time services are rendered.\"}]","Outpatient Prior Authorization Fax Form - Ver12 | PDF",1789620950]