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Ambetter Outpatient Prior Authorization Fax Form

Ambetter, Centene's marketplace plan brand, uses this outpatient authorization form for fax requests for outpatient services, behavioral health, DME and transplant services, and for additional units on an existing authorization. A clinician meets it when ordering a service on the plan's prior authorization list. Each state plan publishes its own version with its own fax lines, and the plan reviews the clinical information attached.

Who completes it

The requesting provider completes the member, ordering provider and servicing provider sections, CPT or HCPCS codes, ICD-10 diagnosis, dates and the service type code. Urgent requests must be signed by the requesting physician.

Submitting and payment

How to submit it
Fax it to the state plan's medical, behavioral health or transplant utilization management line printed at the top; the plan's provider portal is the preferred route.
Who pays
The form states an authorization is not a guarantee of payment; the member must be eligible when services are given and the service must be covered and medically necessary.

Good to know

  • On the Washington version, standard requests are decided within 5 calendar days of receiving all necessary information; turnaround times vary by state plan.
  • Urgent means needing treatment within 48 hours to avoid complications or severe pain for a condition that is not life threatening, and needs the physician's signature for priority.
  • Incomplete forms with missing required fields are rejected, and missing clinical information can delay the decision.
  • Inpatient admissions use the separate Ambetter Inpatient Prior Authorization Fax Form, and some states mandate their own uniform form instead.

Get the official form

Download the current version from the source each time; forms change without notice.

Ambetter Outpatient Prior Authorization Fax Form

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

What service type codes are on the Ambetter outpatient authorization form?

Examples include 171 outpatient surgery, 201 sleep study, 205 genetic testing and counseling, 249 home health, 290 hyperbaric oxygen, 650 radiation therapy and 993 transplant evaluation. Behavioral health codes cover ECT, intensive outpatient, psychological testing, ABA or TMS and partial hospitalization, and DME uses 417 rental or 120 purchase.

Is the Ambetter outpatient form the same in every state?

No. Each Centene state plan publishes its own version with its own fax numbers and turnaround times, for example Home State Health in Missouri. Where a state mandates a uniform prior authorization form, such as Arizona or Nebraska, that form replaces the Ambetter version.