Safety Net Outpatient Prior Authorization Form - Outpatient

Sep 17, 2026

This outpatient prior authorization form collects member information, Medicaid/member ID, requested and servicing provider details (NPI, TIN, contact information), and the authorization request specifics. It requires procedure codes (CPT/HCPCS with modifiers), start and end/admission and discharge dates, diagnosis codes (ICD-10), and total units/visits/days. It includes a service type selection list, instructions for urgent vs standard requests, and uploading prior authorization with clinical documentation to the SDS portal. Required fields must be completed to avoid rejection; incomplete clinical information can delay determination. Authentication and confidentiality terms explain eligibility and that authorization does not guarantee payment.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Instructions for Completing the Form

Member Information

Requesting Provider Information

Servicing Provider/Facility Information

Authorization Request Details

Outpatient Service Type Selection

Required Submission Notes and Disclaimer

IMPORTANT INSTRUCTIONS FOR COMPLETING THIS FORM Please read these instructions carefully before completing this form. Thankyou! 􀂃 For each authorization request, please print a new form directly from our website. Do not make copies of the form for future use. 􀂃 Type your responses whenever possible. Handwriting is difficult for our automated ocular recognition software system to read; however, if you need to handwrite, please print and use black ink. 􀂃 Upload the prior authorization request with corresponding clinical documentation to our SDS portal at [Provider.ExcellusBCBS.com/authorizations/sds-portal](Provider.ExcellusBCBS.com/authorizations/sds-portal). 􀂃 Documents uploaded after 5 p.m. will not be processed until the following business day. 􀂃 To improve processing time, upload prior authorization requests and medical records one member at a time. 􀂃 Mark prior authorization requests as Urgent or Standard in the appropriate form field. If you handwrite “urgent” on the form or in the notes on a coverage page, it may be missed. 􀂃 If you do not receive a determination within the requested time frame, please callus before resending documents. If you do not call, a duplicate request could be processed, which delays intake. OUTPATIENT AUTHORIZATION FORM Request for additional units. Existing Authorization Units Standard requests Urgent request- I certify this request is urgent and medically necessary to treat an injury, illness, or condition (not life threatening) to avoid complications and unnecessary suffering or severe pain. After hours, weekends, and holidays requests will be processed the next business day as received. * INDICATES REQUIRED FIELD *Date of Birth MEMBER INFORMATION *Medicaid/Member ID Last Name, First (MMDDYYYY) REQUESTING PROVIDER INFORMATION *Requesting NPI *Requesting TIN Requesting Provider Contact Name Requesting Provider Name Phone *Fax SERVICING PROVIDER / FACILITY INFORMATION Same as Requesting Provider *Servicing NPI *Servicing TIN Servicing Provider Contact Name Servicing Provider/Facility Name Phone Fax AUTHORIZATION REQUEST *Primary Procedure Code (CPT/HCPCS) (Modifier) Additional Procedure Code (CPT/HCPCS) (Modifier) Additional Procedure Code (CPT/HCPCS) (Modifier) Additional Procedure Code (CPT/HCPCS) (Modifier) *Start Date OR Admission Date (MMDDYYYY) End Date OR Discharge Date (MMDDYYYY) *Diagnosis Code (ICD-10) Total Units/Visits/Days *1086* | *OUTPATIENT SERVICE TYPE (Enter the Service type number in the boxes) | | 202 Pain Management
101 Physical Therapy
147 Prosthetics
(Purchase Price)
701 Speech Therapy
411 Surgical Procedures
310 Vision
DME
417 Rental
120 Purchase
(Purchase Price) | | --- | --- | --- | | 760 Air Ambulance (Non-Emergent)
712 Cochlear Implants & Surgery
911 Dental Anesthesia-Office Visit
709 Genetic Testing
249 Home Health
305 Long Term Services & Support | 790 Occupational Therapy
497 Office Visit/Specialty Consult
927 Outpatient Hospice
794 Outpatient Services
210 Orthotics
(Purchase Price) | | | 912 Oxygen Equipment/Gas Supply | | | ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED. COPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION. Disclaimer: 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. Confidentiality: 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 immediatel

FAQs

What should you do for each authorization request when submitting this form?

Print a new form directly from the website for each authorization request and do not make copies for future use.

How should urgent requests be indicated?

Mark the request as Urgent or Standard in the appropriate field. Handwriting “urgent” on the form or in coverage-page notes may be missed.

What happens if required fields or supporting clinical information are incomplete?

Incomplete forms will be rejected. Lack of clinical information may result in a delayed determination.

Sep 17, 2026

Upload by Ben Jamin