Get Amerigroup Precertification Form

Filling out the Amerigroup Precertification Form online is an essential step in securing necessary approvals for healthcare services. This guide provides detailed, user-friendly instructions to help you navigate this process smoothly.

Follow the steps to efficiently complete the form online.

1. Press the ‘Get Form’ button to retrieve the Amerigroup Precertification Form and open it for editing.
2. In the Member Information section, enter the required details including the member's name, Amerigroup number, address, city, state, zip code, Medicaid number, date of birth, and any other insurance or worker’s compensation information. Ensure all entries are clear to avoid delays.
3. Next, fill out the Referring Provider Information. Include the referring provider's name, office contact name, Medicaid provider number, Amerigroup number, and all necessary phone and fax numbers. This section may also require the group practice number and NPI number.
4. For the Specialist Consult, input the consultant's name, Amerigroup provider number, NPI number, address, phone, and fax numbers. Additionally, provide the appropriate ICD-9 code, the reason for the referral, previous medical history, and the number of visits required.
5. If applicable, complete the Maternity Care section according to the instructions for pregnancy-related services. Use the Maternity Notification form when necessary.
6. In the Diagnostic Study segment, provide the facility name, date of service, diagnosis or reason for referral, procedure or CPT-4 code, and previous studies or treatments.
7. The Surgery Request section requires the surgeon's full name, date of service, inpatient or outpatient status, facility name, diagnosis, procedure or CPT-4 code, and any previous studies or treatments related to the surgery.
8. For other clinical information needed, select the appropriate checkboxes and fill in the referred to provider's name, Amerigroup provider number, NPI number, diagnosis, procedure or CPT-4 code, and previous studies or treatments.
9. Attach any clinical information needed to support medical necessity. Review all entries to ensure accuracy and completeness, as only completed referrals will be processed.
10. Once you have filled in all necessary sections, you can save your changes, download the completed form, or print it for your records.

Complete your Amerigroup Precertification Form online today to ensure timely processing of your healthcare services.