Get Precertification Form

Filling out the Precertification Form online is a straightforward process that requires attention to detail. This guide will provide you with comprehensive instructions to ensure that your submission is complete and timely, helping to prevent any delays in processing your request.

Follow the steps to successfully complete the Precertification Form.

1. Click ‘Get Form’ button to obtain the Precertification Form and open it in the online editor.
2. Enter today's date in the designated field. This ensures that your request is processed with the most current information.
3. Fill in the provider return fax and provider return phone fields to ensure that communication can be conducted easily.
4. Provide the member information, including their first name, last name, address, date of birth, and Amerigroup member ID. It is important to be accurate to avoid processing issues.
5. Complete the referring provider section with their full name, NPI (National Provider Identifier), office contact name, address, and specialty.
6. In the servicing provider section, input the necessary details such as full name, NPI, office contact name, address, and specialty.
7. For the servicing facility, enter the required information, including full name, NPI, facility contact name, and address.
8. Indicate the date or date range of the requested service and provide the corresponding provider ID, office phone, and location details.
9. Select the appropriate types of service by checking all that apply, such as outpatient, skilled nursing facility, or home health.
10. Fill in the ICD-10 codes and CPT codes, ensuring to include the requested units and the number of visits required.
11. Select the place of service, ensuring to accurately reflect where the service will be provided, such as a hospital or office.
12. Provide any additional information that could support your request, and attach any relevant clinical information and documents.
13. If this submission is a request for extension or modification of an existing authorization, include the authorization number.
14. Before submission, review all entered information for accuracy. Once confirmed, save changes, download, print, or share the form as needed.

Complete your Precertification Form online today to ensure a smooth and efficient processing experience.