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OUTOFNETWORK PREAUTHORIZATION AND EXCEPTION REQUEST Forms form is for outofnetwork providers requesting application of in network benefits for their services. Complete and fax to Care Management at

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What is out-of-network pre-authorization?

Out-of-network pre-authorization is the process of obtaining approval from an insurance provider before receiving medical services from a healthcare provider that is not within the insurance plan's network.

Who is required to file out-of-network pre-authorization?

The healthcare provider or facility is usually required to file out-of-network pre-authorization on behalf of the patient.

How to fill out out-of-network pre-authorization?

To fill out out-of-network pre-authorization, the healthcare provider typically submits a request to the insurance company, including detailed information about the planned medical services.

What is the purpose of out-of-network pre-authorization?

The purpose of out-of-network pre-authorization is to ensure that the medical services are deemed necessary and covered by the insurance plan, as well as to establish the cost-sharing responsibilities between the insurance provider and the patient.

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

Information such as the patient's medical history, diagnosis, proposed treatment plan, and estimated costs must be reported on out-of-network pre-authorization.

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