Form 4091c 04043 - Out Of Network Outpatient Prior Authorization

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Out-of-network Outpatient
Prior Authorization Request Form
Today’s date
/
/
Fax to: 888-977-0776
Behavioral health services rendered by out-of-network providers require prior authorization. To request
prior authorization, please complete this form and fax it to us with ALL of the following: a copy of your
license, malpractice insurance face sheet, and a completed W-9.
Member information
/
/
Member name
Member ID #
DOB
Member address
Phone
-
-
City
State
ZIP
Provider information
Provider name
NPI #
Provider address
City
State
ZIP
Tax ID #
Provider phone
-
-
Provider fax
-
-
Licensure
Do you have any special certifications or trainings?
Yes
No
If yes, list the certification/training and date of completion.
Board certified
Yes
No
CANS certified
Yes
No
Do you use a treatment measurement/outcome tool?
Yes
No
If yes, please specify.
Languages spoken
Languages provided by interpreters
Please use this table to request up to 12 sessions at any time throughout the member’s benefit year.
Requested sessions
Submission of this form does not guarantee authorization of your request.
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/
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/
Date range of requested sessions from
to
Code
Modifier*
Sessions
# of sessions requested
90791
Psychiatric diagnostic evaluation (no medical service)
90792
Psychiatric diagnostic evaluation (with medical service)
Individual psychotherapy, 20 – 30 minutes
90832
90833
Individual psychotherapy with medication management,
20 – 30 minutes (must accompany an E/M code)
90834
Individual psychotherapy, 45 minutes
90836
Individual psychotherapy with medication management,
45 minutes (must accompany an E/M code)
90846
Family psychotherapy without patient present
90847
Family psychotherapy with patient present
90853
Group psychotherapy
99201-
E/M codes, new patients
99205**
99211-
E/M codes, established patients
99215**
Other:
* Modifiers: Master’s level — HO; Psychiatrist — U6; Clinical specialist — SA; Registered nurse — TD; Psychologist — AH
** Select the appropriate E/M code range. We will reimburse your claim for authorized services if you bill a code within this range.
Form available at
Phone: 888-257-1985
4091C 04043
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