Get Amerigroup Precertification

Filling out the Amerigroup Precertification form online is a straightforward process that helps ensure timely authorization for necessary services. This guide provides clear instructions to help you navigate each section of the form confidently.

Follow the steps to complete the Amerigroup Precertification form.

1. Press the ‘Get Form’ button to obtain the Amerigroup Precertification form and open it in your editing tool.
2. Begin by entering today's date in the appropriate field. This date is important for tracking the submission of your request.
3. Fill out the provider return fax number where the completed authorization should be sent.
4. In the member information section, enter the member's first and last name, Amerigroup member ID, address, city, state, ZIP code, date of birth, and contact phone number.
5. Provide any additional information about the member, including the referral information. Indicate whether the referring provider is participating or nonparticipating.
6. Complete the provider details, including the referring provider's full name, NPI, provider ID, tax ID number, office contact name, office phone, office fax, address, city, state, ZIP code, and specialty.
7. Next, fill out the servicing provider's details using the same format as the referring provider. Make sure to indicate if they are participating or nonparticipating.
8. Enter the servicing facility information, following the same format. Confirm participation status here as well.
9. In the requested service section, check all types of services being requested and specify the date or date range of the service.
10. List the relevant ICD-10 and CPT codes, ensuring you include any requested units for the CPT codes.
11. Select the type of service from the provided options, such as outpatient, inpatient, or durable medical equipment, among others.
12. Indicate the place of service, choosing from options such as hospital, office, or home.
13. Complete any additional information that may support your request. Make sure to provide all required clinical information and provider contact details.
14. If applicable, include the authorization number for requests related to an extension or modification of an existing authorization.
15. Review your completed form for accuracy, then save any changes, download a copy for your records, and print or share as needed.

Start completing your Amerigroup Precertification form online today for efficient processing.