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Outofnetwork Outpatient Prior Authorization Request Form Today's date / Fax to: 8889770776 For Tufts Health Unify, fax to: 8573046304 / Behavioral health services rendered by outofnetwork providers

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What is out-of-network outpatient prior authorization?

Out-of-network outpatient prior authorization is a process that requires approval from a health insurance plan before receiving medical services from a provider that is not in the plan's network.

Who is required to file out-of-network outpatient prior authorization?

Both the healthcare provider and the patient may be required to file out-of-network outpatient prior authorization, depending on the specifics of the insurance plan.

How to fill out out-of-network outpatient prior authorization?

To fill out out-of-network outpatient prior authorization, the healthcare provider must provide necessary medical information and submit the request to the insurance plan for approval.

What is the purpose of out-of-network outpatient prior authorization?

The purpose of out-of-network outpatient prior authorization is to ensure that medical services provided by out-of-network providers are necessary and covered by the insurance plan.

What information must be reported on out-of-network outpatient prior authorization?

The out-of-network outpatient prior authorization may require information such as the patient's medical history, the reason for seeking services from an out-of-network provider, and the estimated cost of the services.

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