Follow the steps to successfully complete your precertification request.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Enter today’s date in the designated field to provide a proper time reference for your request.
3. Complete the member information section, including the first name, last name, Amerigroup member ID, address, city, state, ZIP code, date of birth, and phone number.
4. Provide details for the referring provider, such as full name, NPI (National Provider Identifier), office contact name, address, and specialty.
5. Fill in the servicing provider information, including full name, NPI, office contact name, address, and specialty.
6. Enter the servicing facility details, providing the name, NPI, contact name, address, and associated phone and fax numbers.
7. Specify the requested service by checking all applicable types, including outpatient, emergent inpatient, skilled nursing, home health, and others as relevant.
8. Fill in the ICD-10 code(s) and CPT code(s), including the requested units for accurate processing.
9. Indicate the date or range of service in the appropriate field.
10. Add any additional information that may support your request, ensuring to include clinical details and provider contacts.
11. If this is a request for extension or modification of an existing authorization, provide the authorization number.
12. Once all sections are complete, review the form for accuracy, and then save changes, download, print, or share the completed form as necessary.

Complete your DC Amerigroup Precertification Request online today to ensure timely processing of your authorization.