Get Hospice Precertification Request - Amerigroup

Completing the Hospice Precertification Request form for Amerigroup is a crucial step in ensuring timely access to hospice care. This guide provides clear, step-by-step instructions to assist users in accurately filling out the form online.

Follow the steps to complete your precertification request.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Enter today's date in the designated field at the top of the form. This ensures that your request is processed in a timely manner.
3. Fill in the member information section. Provide the member's full name, Amerigroup ID number, address, city, state, and ZIP code, Medicaid number, and date of birth to accurately identify the person needing hospice services.
4. Complete the hospice agency information section. Input the name of the hospice agency, their NPI number, Amerigroup provider number, office contact name, and the contact's phone and fax numbers.
5. Fill in any other clinical information needed. Include the diagnosis code, procedure code, and the effective date of the procedure code. If applicable, indicate the nursing facility where hospice services will be provided, along with its NPI and Amerigroup provider numbers.
6. If relevant, enter the date of death, date of transfer to another provider, and date of hospice revocation in their respective fields. This information is vital for processing the precertification request correctly.
7. Select the appropriate options for the duration of the hospice care being requested by checking the boxes for the initial 90 days, secondary 90 days, or subsequent 60 days.
8. Attach the Notice of Election Statement as required and ensure that all sections are thoroughly reviewed for accuracy.
9. Once all information is complete, save changes, and download, print, or share the form as needed to submit the hospice precertification request.

Complete your Hospice Precertification Request form online today to ensure prompt hospice care.