Get the free Pre-certification Fax Form for Out-of-Area

Form for pre-certification of inpatient services for health plan members, including necessary patient and facility information.

How to fill out pre-certification fax form for

How to fill out Pre-certification Fax Form for Out-of-Area

1. Obtain the Pre-certification Fax Form from your insurance provider's website or customer service.
2. Fill in the patient's personal information, including name, date of birth, and policy number.
3. Provide details of the out-of-area service being requested, including the type of service and the name of the facility.
4. Include medical justification for the out-of-area service, such as doctor's notes or referral letters.
5. Fill in the healthcare provider's information, including name, address, and contact details.
6. Ensure that the form is signed by the patient or their authorized representative.
7. Double-check all information for accuracy and completeness before submission.
8. Fax the completed form to the number provided by your insurance provider, keeping a copy for your records.
9. Follow up with the insurance provider to confirm receipt and check the status of the pre-certification request.

Who needs Pre-certification Fax Form for Out-of-Area?

1. Patients seeking medical services outside of their usual service area.
2. Healthcare providers who need approval for out-of-area treatments for their patients.
3. Insurance companies requiring documentation for out-of-area service requests.

People Also Ask about

What does it mean to need prior authorization?

Prior authorization is the approval from your health insurance that may be required for a service, treatment, or prescription to be covered by your plan if it's not an emergency. Prior authorization does not guarantee payment, but it does make it more likely your health plan will cover the cost.

What is a prior authorization for Blue Shield CA?

Prior authorization means that your doctor must get approval from Blue Shield before prescribing specific medications or performing a particular medical service or operation. Without this prior approval, Blue Shield may not pay for your medication or medical procedure, and you will have to pay out of pocket.

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What is Pre-certification Fax Form for Out-of-Area?

The Pre-certification Fax Form for Out-of-Area is a document used to request pre-approval for medical services or procedures that are outside of a patient's primary network area, ensuring necessary authorization is obtained before receiving care.

Who is required to file Pre-certification Fax Form for Out-of-Area?

Patients who are seeking medical services or procedures outside of their primary network area must file the Pre-certification Fax Form for Out-of-Area. This typically includes those on managed care plans or specific insurance policies that require pre-authorization.

How to fill out Pre-certification Fax Form for Out-of-Area?

To fill out the Pre-certification Fax Form for Out-of-Area, provide essential details such as patient information, insurance information, details of the requested procedure, the provider's information, and any relevant medical history or documentation required by the insurance company.

What is the purpose of Pre-certification Fax Form for Out-of-Area?

The purpose of the Pre-certification Fax Form for Out-of-Area is to obtain advance approval from the insurance provider for medical services outside the standard network, ensuring coverage for those services and avoiding unexpected out-of-pocket expenses.

What information must be reported on Pre-certification Fax Form for Out-of-Area?

The information that must be reported on the Pre-certification Fax Form for Out-of-Area includes the patient's name, date of birth, insurance policy number, details of the requested service or procedure, the provider's contact information, and any supporting medical documentation.