Get Amerihealth In Network Exception Request Form 2017-2025

Filling out the AmeriHealth In Network Exception Request Form online is a straightforward process designed to help users submit their requests efficiently. This guide provides step-by-step instructions to ensure that you complete the form accurately and provide all necessary information.

Follow the steps to complete your form effectively

1. Press the ‘Get Form’ button to obtain the In Network Exception Request Form and open it for editing.
2. Begin by entering the date at the top of the form and identify who completed the form by providing their name and phone number.
3. Select the reason for your request from the options provided, ensuring you choose the most applicable one based on your situation.
4. Provide member information by filling in the Member ID, effective date of coverage, previous insurance carrier, and the subscriber’s name. Include the patient’s name and date of birth, along with their street address, city, state, zip code, and home phone number.
5. Enter doctor information, including the doctor’s name, NPI or TIN, address details, office phone number, specialty, and the office contact person.
6. Document the diagnosis or condition being treated, ensuring to include the corresponding ICD-10 code. Additionally, specify the CPT code(s) for the service or procedure requested, especially for post-op requests or scheduled procedures.
7. Indicate how long the treatment is expected to continue and the number of visits being requested, along with the frequency of appointments (weekly, monthly, quarterly).
8. Provide the date of the patient’s next appointment.
9. Lastly, make sure to submit the last office visit note, treatment plan, and any relevant clinical documentation as required.
10. Once all sections are filled, review your information for accuracy. You can then save changes, download the form, print it, or share it as needed.

Get started with your AmeriHealth In Network Exception Request Form online today!