Get Amerigroup Precertification Request 2016-2025

Completing the Amerigroup Precertification Request online is an essential process for obtaining necessary approvals for medical services. This guide provides detailed instructions to assist you in accurately filling out the form to ensure that your request is processed efficiently.

Follow the steps to complete your precertification request accurately.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Provide today's date in the designated section at the top of the form. This is important for tracking and reference.
3. Enter the member information. Fill in the name (last, first), Amerigroup ID number, date of birth, address, city, state, and ZIP code. If applicable, include the state Medicaid ID number and details about other insurance or workers' compensation.
4. In the service/prior authorization request section, specify the type of service for which you are requesting authorization. Check all applicable boxes, including options for durable medical equipment, therapy services, home health, hospice, and others.
5. Indicate the place of service by selecting relevant options such as office or home. Then, provide the requested dates of service.
6. Include the ICD-10 diagnosis code(s) and any relevant CPT codes in the designated fields to identify the medical conditions and procedures being authorized.
7. Specify the number of units or visits required, along with the frequency of service requested in the appropriate section.
8. List the servicing provider's information. This includes the provider's name, specialty, Amerigroup provider/group ID number, office contact name, network status (par or out-of-network), phone number, fax number, tax ID number, address, NPI number, and city, state, and ZIP code.
9. Complete the ordering/referring provider section with the same relevant details.
10. Fill out the facility information, including facility name, Amerigroup provider/facility ID number, office contact name, network status, and all relevant contact details.
11. If applicable, complete the maternity care section, citing if this request is for initial notification of pregnancy or other related services.
12. Fill out the section for surgery requests, including the surgeon's full name and relevant facility information, indicating whether the procedure will be inpatient or outpatient.
13. Review the completed form for accuracy. Once verified, you may save changes, download, print, or share the form as needed.

Start your precertification request online today to ensure a smooth process!