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

Provide a detailed explanation why the requested services can only be provided by this specific out-of-network provider, including the patient’s presenting symptoms, prior treatments or providers seen, dates of last visits if relevant, and any clinical or logistical reasons that justify using this provider.

Enter the facility's street address, including building number, street name and any suite or unit number.

Enter the city for the facility's mailing address.

Enter the state where the facility is located (use the two-letter U.S. postal abbreviation or full state name).

Enter the ZIP code for the facility's address (5-digit or ZIP+4 if available).

Check this box when the service is provided at a freestanding infusion center (not part of a hospital).

Check this box when the service is provided in the patient's home.

Check this box when the service is provided in an office or clinic setting.

Check this box when the facility location is not listed above and write the location type in the adjacent blank.

Enter the specific facility location type when none of the provided options (Freestanding infusion center, Home, Office, etc.) apply; provide a short descriptive name for the 'Other' facility type. Fill only if 'Other (specify)' is 'Yes'.

Enter the full legal or commonly used name of the facility where services are provided.

Enter the full name of the primary contact person at the facility (e.g., administrator, director, or staff member responsible for inquiries).

Enter the facility's main phone number, including the area code, as it should appear for contact.

Enter the facility's fax number, including the area code, used for sending documents.

Provide the facility's federal Tax Identification Number (EIN) required for billing and tax purposes.

Provide the facility's National Provider Identifier (NPI) number required for provider identification.

Check this box when the patient has NOT seen this provider in the past.

Check this box when the patient HAS seen this provider in the past (and provide the date of last visit if requested).

Check this box if the facility is an inpatient hospital.

Check this box if the inpatient hospital provides medical inpatient services.

Check this box if the inpatient hospital provides surgical inpatient services.

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

Check this box if the inpatient hospital provides psychiatric inpatient services.

Check this box if the facility offers inpatient treatment for eating disorders.

Check this box if the facility provides inpatient substance use treatment at ASAM Level 4.0.

Check this box if the facility provides substance use rehabilitation services at ASAM Level 3.7.

Check this box if this request is NOT a follow-up to an emergency (for example, not related to prior ER treatment or emergency surgery).

Check this box if this request IS a follow-up to an emergency (for example, related to prior ER treatment or emergency surgery); if checked, provide the date of the last visit when requested.

Check this box when the facility being reported is a lower level of care (LLOC) rather than an inpatient hospital option.

Check this box when the facility is an inpatient rehabilitation facility (IPR) providing rehabilitative services.

Check this box when the facility provides specialized neurological rehabilitation services.

Check this box when the facility is a skilled nursing facility (SNF) that provides skilled nursing care.

Check this box when the facility is a long-term acute care hospital (LTAC) providing extended acute inpatient care.

Check this box when the facility is a residential treatment center offering detoxification services at ASAM Level 3.7 with withdrawal management (WM).

Enter the full name of the member or patient as it appears on their insurance records.

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

Enter any alphabetic prefix that is part of the member's ID (letters that precede the numeric portion).

Enter the numeric portion of the member's identification number exactly as shown on the member's insurance card.

Enter any suffix or additional characters that follow the main member ID, if applicable.

Check this box if the facility is an outpatient hospital (a hospital providing outpatient services rather than inpatient care).

Check this box if the facility is an ambulatory surgical center (a facility that provides same-day surgical care without inpatient admission).

Enter the primary procedure or CPT/HCPCS code for Procedure Row 1 that identifies the service being requested.

Enter any applicable modifier(s) for Procedure Row 1 (e.g., LT, RT, NU, RR), separated by commas if you need to include more than one.

Enter the number of units or quantity billed for the procedure on Row 1.

Enter the ICD diagnosis code (ICD-10-CM or other applicable code) that supports the medical necessity for Procedure Row 1.

Enter the procedure or CPT/HCPCS code for the service on this row (e.g., five-digit CPT or HCPCS alphanumeric code).

Enter any modifier(s) that apply to the procedure on this row (e.g., LT, RT, 59), separated by commas if listing more than one.

Enter the number of units or quantity of the procedure provided for this row (for example: 1, 2, etc.).

Enter the ICD diagnosis code that supports this procedure (include the decimal point and full ICD-10 code where applicable).

Enter the procedure or CPT code that identifies the service provided for Row 3 (e.g., a CPT, HCPCS, or other procedure code).

Enter any modifier codes associated with the Row 3 procedure (e.g., RT, LT, 59); if more than one, separate them with commas.

Enter the number of units or quantity delivered for the Row 3 procedure (for example, number of visits, sessions, or service units).

Enter the ICD diagnosis code that supports or corresponds to the Row 3 procedure (include decimal or letter characters as required by the ICD format).

Enter the CPT or procedure code for Procedure Row 4 that describes the service performed (for example, 99213).

Enter any applicable procedure modifier(s) for Row 4 (for example LT, RT, NU, RR); separate multiple modifiers with commas.

Enter the quantity or number of units provided for the procedure on Row 4 (for example 1).

Enter the ICD diagnosis code that justifies medical necessity for the procedure on Row 4 (for example M54.5).

Check this box when you are requesting authorization for transition of care services to ensure continuity as the patient moves between providers or care settings.

Check this box when you are requesting services specifically to maintain continuity and coordination of the patient’s ongoing care across providers or settings.

Check this box when you are requesting a change to the patient’s benefit level (a benefit level exception) due to clinical need.

Check this box when you are requesting an extension of an already approved Benefit Level Exception (BLE) beyond its original timeframe. Fill only if 'Benefit Level Exception' is 'Yes'.

Check this box when you are requesting a Single Case Agreement (SCA) to authorize out-of-network care for a specific patient/case.

Check this box when you are requesting an extension of an existing Single Case Agreement (SCA) beyond the original approval period. Fill only if 'Single Case Agreement (SCA)' is 'Yes'.

Enter the full legal or billing name of the requesting provider (individual, practice, or organization).

Enter the full name of the primary contact person at the requesting provider’s office.

Enter the provider’s street mailing address, including suite or floor number if applicable.

Enter the city for the provider’s mailing address.

Enter the U.S. state or territory for the provider’s mailing address (use the two-letter abbreviation if preferred).

Enter the ZIP code for the provider’s mailing address.

Enter the provider’s telephone number including area code and extension if applicable (for example, 555-555-1234).

Enter the provider’s fax number including area code, if available.

Enter the provider’s taxpayer identification number (EIN or SSN) used for billing or tax purposes.

Enter the provider’s National Provider Identifier (NPI) number assigned for health care providers.

Enter the full legal name of the servicing provider or organization responsible for delivering the services. Fill only if 'No. Continue with servicing provider information below.' is 'Yes'.

Enter the full name of the primary contact person at the servicing provider (first and last name). Fill only if 'No. Continue with servicing provider information below.' is 'Yes'.

Enter the street address of the servicing provider, including suite or unit number if applicable. Fill only if 'No. Continue with servicing provider information below.' is 'Yes'.

Enter the city where the servicing provider's address is located. Fill only if 'No. Continue with servicing provider information below.' is 'Yes'.

Enter the two-letter state abbreviation for the servicing provider's address. Fill only if 'No. Continue with servicing provider information below.' is 'Yes'.

Enter the ZIP code for the servicing provider's address (5- or 9-digit ZIP as applicable). Fill only if 'No. Continue with servicing provider information below.' is 'Yes'.

Enter the servicing provider's telephone number including area code and extension if applicable. Fill only if 'No. Continue with servicing provider information below.' is 'Yes'.

Enter the servicing provider's fax number including area code. Fill only if 'No. Continue with servicing provider information below.' is 'Yes'.

Provide the servicing provider's Tax Identification Number (TIN/EIN) issued by the IRS. Fill only if 'No. Continue with servicing provider information below.' is 'Yes'.

Provide the servicing provider's National Provider Identifier (NPI) number. Fill only if 'No. Continue with servicing provider information below.' is 'Yes'.

Check this box if the servicing provider is the same as the requesting provider; if checked, skip to Section D and do not fill the servicing provider information below.

Check this box if the servicing provider is NOT the same as the requesting provider; if checked, continue and complete the servicing provider information fields below.

Check this box when the request is urgent (e.g., seriously jeopardizes the patient’s life/health or ability to regain maximum function) and will be signed by the requesting provider with supporting documentation.

Enter the full printed name of the signing provider attesting that the request meets the urgent definition. Fill only if 'Check this box if this is an urgent request.' is 'Yes'.

Enter the signing provider's professional title or role (for example, 'MD', 'DO', 'PA', 'NP', or department/position). Fill only if 'Check this box if this is an urgent request.' is 'Yes'.

Enter the date when the signing provider signed and attested that the request is urgent. Fill only if 'Check this box if this is an urgent request.' is 'Yes'.