Get Pre-authorization Request Form - Ambetter

Completing the Pre-Authorization Request Form for Ambetter can be straightforward with the right guidance. This guide will help you understand each section of the form and provide clear instructions for submitting your request online.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the Pre-Authorization Request Form and open it for editing.
2. Fill out the date and office contact information in the designated fields. Ensure to include the contact's phone and fax numbers for follow-up communications.
3. Input the attending physician's information, including their name and National Provider Identifier (NPI) number.
4. Complete the patient’s details, including their full name, identification number, health maintenance organization (HMO) plan, date of birth, and group number.
5. Specify the admission and surgery dates, circling whether the procedure is inpatient or outpatient, along with the anticipated length of stay.
6. Provide the facility's name and address, indicating whether it is a participating (PAR) or non-participating (NON-PAR) facility, and include a reason for non-participation, if applicable.
7. Document the diagnosis and procedure, ensuring that the appropriate codes and descriptions are included.
8. Circle the relevant eye(s) for the procedure, and list the corresponding ICD and CPT codes for each. Provide additional ICD and CPT entries as needed.
9. Include a medical reason for the request and the patient’s subjective complaint if applicable. You may attach additional pages if necessary.
10. Ensure the attending physician signs and dates the form, and include the office address for correspondence.
11. After completing the form, save your changes. You can then download or print the form for submission. Make sure to fax the completed form to (877) 865-1077 or mail it to the provided address.

Start filling out your Pre-Authorization Request Form online today to ensure timely processing of your request.