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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.",{"@graph":63,"@context":119},[64,80,102],{"@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/safety-net-outpatient-prior-authorization-form-outpatient/287778/",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/safety-net-outpatient-prior-authorization-form-outpatient/287778.png","ImageObject",442,249,{"name":88,"@type":89},"Ben Jamin","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-26","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",7,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What should you do for each authorization request when submitting this form?","Question",{"text":109,"@type":110},"Print a new form directly from the website for each authorization request and do not make copies for future use.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How should urgent requests be indicated?",{"text":114,"@type":110},"Mark the request as Urgent or Standard in the appropriate field. Handwriting “urgent” on the form or in coverage-page notes may be missed.",{"name":116,"@type":107,"acceptedAnswer":117},"What happens if required fields or supporting clinical information are incomplete?",{"text":118,"@type":110},"Incomplete forms will be rejected. Lack of clinical information may result in a delayed determination.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},287778,1790182492,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"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":9},2336478466772,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","IMPORTANT INSTRUCTIONS FOR COMPLETING THIS FORM  \nPlease read these instructions carefully before completing this form. Thankyou!  \n􀂃 For each authorization request, please print a new form directly from our website.  \nDo not make copies of the form for future use.  \n􀂃 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.  \n􀂃 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).  \n􀂃 Documents uploaded after 5 p.m. will not be processed until the following business day.  \n􀂃 To improve processing time, upload prior authorization requests and medical records one member at a time.  \n􀂃 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.  \n􀂃 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.  \nOUTPATIENT AUTHORIZATION FORM  \nRequest for additional units. Existing Authorization Units  \nStandard requests  \nUrgent 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.  \nAfter hours, weekends, and holidays requests will be processed the next business day as received.  \n* INDICATES REQUIRED FIELD    \n*Date of Birth  \nMEMBER INFORMATION  \n*Medicaid/Member ID  \nLast Name, First  \n(MMDDYYYY)  \nREQUESTING PROVIDER INFORMATION  \n*Requesting NPI *Requesting TIN Requesting Provider Contact Name  \nRequesting Provider Name Phone *Fax  \nSERVICING PROVIDER / FACILITY INFORMATION  \n Same as Requesting Provider  \n*Servicing NPI *Servicing TIN Servicing Provider Contact Name  \nServicing Provider/Facility Name Phone Fax  \nAUTHORIZATION REQUEST  \n*Primary Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \n*Start Date OR Admission Date  \n(MMDDYYYY)  \nEnd Date OR Discharge Date  \n(MMDDYYYY)  \n*Diagnosis Code  \n(ICD-10)  \nTotal Units/Visits/Days  \n*1086*  \n\n| *OUTPATIENT SERVICE TYPE (Enter the Service type number in the boxes) |  | 202 Pain Management\u003Cbr>101 Physical Therapy\u003Cbr>147 Prosthetics\u003Cbr>(Purchase Price)\u003Cbr>701 Speech Therapy\u003Cbr>411 Surgical Procedures\u003Cbr>310 Vision\u003Cbr>DME\u003Cbr>417 Rental\u003Cbr>120 Purchase\u003Cbr>(Purchase Price) |\n| --- | --- | --- |\n| 760 Air Ambulance (Non-Emergent)\u003Cbr>712 Cochlear Implants & Surgery\u003Cbr>911 Dental Anesthesia-Office Visit\u003Cbr>709 Genetic Testing\u003Cbr>249 Home Health\u003Cbr>305 Long Term Services & Support | 790 Occupational Therapy\u003Cbr>497 Office Visit/Specialty Consult\u003Cbr>927 Outpatient Hospice\u003Cbr>794 Outpatient Services\u003Cbr>210 Orthotics\u003Cbr>(Purchase Price) |  |\n| 912 Oxygen Equipment/Gas Supply |  |  |\n\nALL 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.  \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 immediatel","cbCaiiIKmByOKUSh","https://ap.wps.com/l/cbCaiiIKmByOKUSh","pdf",864276,"English","# Instructions for Completing the Form\n# Member Information\n# Requesting Provider Information\n# Servicing Provider/Facility Information\n# Authorization Request Details\n# Outpatient Service Type Selection\n# Required Submission Notes and Disclaimer","[{\"question\":\"What should you do for each authorization request when submitting this form?\",\"answer\":\"Print a new form directly from the website for each authorization request and do not make copies for future use.\"},{\"question\":\"How should urgent requests be indicated?\",\"answer\":\"Mark the request as Urgent or Standard in the appropriate field. Handwriting “urgent” on the form or in coverage-page notes may be missed.\"},{\"question\":\"What happens if required fields or supporting clinical information are incomplete?\",\"answer\":\"Incomplete forms will be rejected. Lack of clinical information may result in a delayed determination.\"}]","Safety Net Outpatient Prior Authorization Form - Outpatient | PDF",1789632720]