Get Prior Authorization Form - Providers - Forms - Amerihealth Caritas Vip Care Plus. Provider Forms

Filling out the Prior Authorization Form is a crucial step in ensuring that necessary services under the AmeriHealth Caritas VIP Care Plus plan are authorized. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Enter the date of the request in the designated field. This should reflect the current date when the form is being completed.
3. Fill in the service start date or procedure date, which indicates when the requested service is expected to commence.
4. Provide the member's name and AmeriHealth Caritas VIP Care Plus member ID. Ensure these details match the information on file.
5. Input the member's date of birth, using the correct format as required by the form.
6. Enter your name as the provider contact, along with the provider contact phone number and fax number.
7. Complete the requesting provider section by entering your name, National Provider Identifier (NPI), and tax identification number.
8. If applicable, provide the name and NPI of the referring or attending provider, ensuring additional information is included if the two providers differ.
9. Record the diagnosis code using the ICD-9 format and the specific procedure authorization requested, including the CPT or HCPCS code.
10. Attach any pertinent clinical documents to the fax to facilitate a timely review of your request.
11. Fax your completed request form and attachments to 1-866-263-9036.
12. Upon completion, review all entered information for accuracy before finalizing.

Start filling out your Prior Authorization Form online now to ensure timely service authorization.