Out-of-Network Pre-Authorization and Exception Request Form Instructions

Provide a detailed explanation of why the services noted above can only be provided by this particular out-of-network provider.

Check this box if the request is not a follow-up to an emergency.

Check this box if the request is a follow-up to an emergency (e.g., ER treatment/emergency surgery).

Enter the facility's phone number, including the area code.

Enter the facility's fax number, including the area code.

Provide the required Tax ID for the facility.

Provide the required National Provider Identifier (NPI) for the facility.

Provide the full legal name of the facility.

Enter the name of the primary contact person for the facility.

Enter the street address of the facility.

Enter the city where the facility is located.

Enter the state where the facility is located.

Enter the ZIP code of the facility.

Enter the first procedure code or CPT code.

Enter the modifier for the first procedure, such as LT, RT, NU, or RR.

Enter the number of units for the first procedure.

Enter the first ICD diagnosis code.

Enter the CPT or procedure code for the fourth procedure or service.

Enter the modifier code for the fourth procedure, such as LT, RT, NU, or RR.

Enter the number of units for the fourth procedure or service.

Enter the ICD diagnosis code for the fourth diagnosis.

Provide the full name of the member or patient.

Provide the member's or patient's date of birth.

Enter the alpha prefix of the member's ID number.

Enter the main part of the member's ID number.

Enter the suffix of the member's ID number.

Check this box if the patient has not seen this provider in the past.

Check this box if the patient has seen this provider in the past.

Check this box if the request is for a transition of care.

Check this box if the request is for continuity and coordination of care.

Check this box if the request is for a benefit level exception.

Check this box if the request is for an extension of a benefit level exception.

Check this box if the request is for a single case agreement (SCA).

Check this box if the request is for an extension of a single case agreement (SCA).

Enter the full name of the requesting provider.

Enter the name of the contact person for the requesting provider.

Enter the street address of the requesting provider.

Enter the city of the requesting provider.

Enter the state of the requesting provider.

Enter the ZIP code of the requesting provider.

Enter the phone number of the requesting provider, including the area code.

Enter the fax number of the requesting provider, including the area code.

Enter the Tax ID of the requesting provider.

Enter the National Provider Identifier (NPI) number of the requesting provider.

Enter the second procedure or CPT code for the medical service.

Enter the second modifier code for the procedure, which can include values like LT, RT, NU, or RR.

Enter the number of units for the second procedure.

Enter the second ICD diagnosis code relevant to the medical service.

Check this box if the servicing provider is the same as the requesting provider, and you can skip to section D.

Check this box if the servicing provider is different from the requesting provider, and you must provide their information below.

Enter the full name of the servicing provider.

Enter the name of the contact person for the servicing provider.

Enter the street address of the servicing provider.

Enter the city of the servicing provider's address.

Enter the state of the servicing provider's address.

Enter the ZIP code of the servicing provider's address.

Enter the phone number, including the area code, for the servicing provider.

Enter the fax number, including the area code, for the servicing provider.

Enter the tax identification number for the servicing provider.

Enter the National Provider Identifier (NPI) for the servicing provider.

Enter the third procedure code or CPT (Current Procedural Terminology) code.

Enter the modifier for the third procedure code, such as LT, RT, NU, or RR.

Enter the number of units for the third procedure.

Enter the third ICD (International Classification of Diseases) diagnosis code.

Check this box if the facility is an inpatient hospital.

Check this box if the inpatient hospital provides medical services.

Check this box if the inpatient hospital provides surgical services.

Check this box if the inpatient hospital includes a neonatal intensive care unit (NICU).

Check this box if the inpatient hospital provides Detox services at ASAM Level 4.0 – WM.

Check this box if the inpatient hospital provides psychiatric services.

Check this box if the inpatient hospital treats eating disorders.

Check this box if the inpatient hospital treats substance use at ASAM Level 4.0.

Check this box if the inpatient hospital provides substance use rehabilitation at ASAM Level 3.7.

Check this box if the facility is an outpatient hospital.

Check this box if the facility is an ambulatory surgical center.

Check this box if the facility provides a lower level of care (LLOC).

Check this box if the lower level of care facility is an inpatient rehabilitation (IPR) center.

Check this box if the lower level of care facility provides neuro rehabilitation.

Check this box if the lower level of care facility provides skilled nursing (SNF).

Check this box if the lower level of care facility provides long-term acute care (LTAC).

Check this box if the lower level of care facility is a residential treatment center (RTC) for detox at ASAM Level 3.7 – WM.

Check this box if the facility is a freestanding infusion center.

Check this box if the facility is a home setting.

Check this box if the facility is an office setting.

Check this box if the facility type is not listed and specify it in the adjacent field.

Specify the type of facility if it is not listed among the provided options.

Check this box if this is an urgent request, understanding that scheduling issues do not qualify as urgent and specific criteria regarding patient health and documentation apply.

Please enter the printed full name of the medical doctor attesting to the urgent request.

Please enter the printed title or role of the medical doctor attesting to the urgent request.

Please provide the date when the medical doctor signed the attestation for the urgent request.