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Click ‘Get Form’ to open the precertification template form in the editor.
Begin by entering today’s date at the top of the form. This helps track when the request was made.
Fill in the member information section, including the member's name, address, Medicaid number, and Amerigroup number. Ensure all details are accurate for eligibility verification.
In the referring provider information section, provide the necessary details such as name, Medicaid provider number, and contact information. Check the appropriate box for where you want the referral faxed back.
Complete the specialist consult section by entering consultant details and ICD-9 code/diagnosis. Include any previous studies or treatments relevant to this referral.
If applicable, fill out sections for maternity care or diagnostic study with specific facility names and procedure codes.
Finally, review all entries for completeness before submitting. Attach any required clinical information to support medical necessity.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (123 Votes)
2012	4.3 Satisfied (70 Votes)

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What is a precertification form?

Prior authorizationsometimes called preauthorization or precertificationis a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage.

How do I write a pre-authorization letter?

How to Write a Pre-authorization Letter for a Medical Procedure The demographic information of the patient (name, date of birth, insurance ID number and more) Provider information (both referring and servicing provider) Requested service/procedure along with specific CPT/HCPCS codes. Diagnosis (ICD code and description)

What is an example of prior authorization?

How do I write a simple letter of authorization? Start with your name and contact information at the top. Include the current date. Write the recipients name and contact information. Clearly state your name and that youre writing to grant authorization to another individual or organization.

How to write a preauthorization letter?

I am writing to request pre-approval for [service] by [name of provider]. I have reviewed my policy and believe that [name of health care plan] is required to cover this service. [Service] is evidence-based and is medically necessary in order to ensure that [Beneficiary] can communicate effectively.

What is an example of precertification?

For example, services that may require pre-certification include outpatient and inpatient hospital services, observation services, invasive procedures, CT, MRI and PET scans, and colonoscopies. Patients are responsible for knowing the pre-certification requirements of their health plans.