Network Exception Request Form for ABA Assessment
This file is a Network Exception Request Form specifically for initial ABA assessments with Evernorth. It is intended for providers seeking network exceptions for their clients. Use this form to ensure proper authorization and clarity in your request.
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How do I fill this out?
To fill out this form, ensure you have all relevant information at hand. Review the instructions carefully and complete each section as clearly as possible. It is crucial to save the form after filling it out before submitting.
How to fill out the Network Exception Request Form for ABA Assessment?
1
Download and save the form to your computer.
2
Complete all required fields with accurate information.
3
Save the completed form using Adobe Acrobat Reader DC.
4
Email the form to ABA@Evernorth.com or fax it to 1.860.687.9230.
5
Check for any omissions or unclear information before submission.
Who needs the Network Exception Request Form for ABA Assessment?
1
Providers who require an authorization for ABA assessments.
2
Caregivers seeking support for their child diagnosed with ASD.
3
Clinics needing to confirm benefits for their patients.
4
Healthcare professionals involved in the clinical diagnosis of ASD.
5
Network administrators looking to process exceptions for out-of-network services.
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What are the instructions for submitting this form?
To submit the Network Exception Request Form, complete all required sections and either email it to ABA@Evernorth.com or fax to 1.860.687.9230. Ensure you have a digital copy saved for your records. It’s advisable to follow up with a phone call to confirm the submission was received.
What are the important dates for this form in 2024 and 2025?
Important deadlines are determined by the specific requirements of your service provider. Make sure to inquire about any upcoming changes in policy or submission dates as they may impact your request for ABA Assessment. Timely submissions are crucial for ensuring authorization.
What is the purpose of this form?
The Network Exception Request Form serves as an essential tool for providers seeking authorization for ABA assessments. By completing this form, providers can request needed network exceptions for patients diagnosed with Autism Spectrum Disorder. It's designed to streamline the authorization process, ensuring that clients receive the care they require.
Tell me about this form and its components and fields line-by-line.
- 1. Customer Name: The full name of the customer needing the assessment.
- 2. Customer ID: An identification number assigned to the customer.
- 3. Date of Birth: The customer's date of birth for reference.
- 4. Home Address: The residential address of the customer.
- 5. Provider Information: Details regarding the provider performing the assessment, including name and credentials.
- 6. Network Exception Rationale: A detailed explanation of why a network exception is being requested.
- 7. Autism Spectrum Disorder Diagnosis: Confirmation of whether the customer has been diagnosed with ASD.
- 8. Standardized Assessment Tools: Name of the assessment tool(s) to be used during the evaluation.
What happens if I fail to submit this form?
Failure to submit this form accurately may result in delays or denial of your request for authorization. It is essential to complete every section thoroughly to ensure proper processing. Incomplete forms can lead to further inquiries or rejections.
- Incomplete Information: Omissions in the form can cause the request to be returned for clarification.
- Incorrect Details: Providing inaccurate information may affect the authorization outcome.
- Lack of Proper Signatures: Failure to sign the document can result in automatic denial of the request.
How do I know when to use this form?
- 1. Request for ABA Assessment: When the provider needs authorization for conducting an ABA assessment.
- 2. Network Exception Request: To formally request a network exception for services that are not available in the client’s network.
- 3. Specialized Care Needs: When the patient requires specialized care that necessitates an out-of-network provider.
Frequently Asked Questions
How do I submit the form once completed?
You can submit the completed form via email to ABA@Evernorth.com or by fax at 1.860.687.9230.
What should I do if I make a mistake on the form?
If you make a mistake, simply edit the section in the PDF editor and save the changes before submitting.
Can I fill out this form digitally?
Yes, you can type directly into the form fields using PrintFriendly's PDF editor.
Is there a deadline for submitting the form?
Please check with your provider or the relevant department for specific deadlines related to your request.
What if my internet goes down while I’m editing?
Make sure to save your progress regularly to avoid losing any information.
Can I share the PDF with others?
Yes, you can easily share the PDF via email or social media through the PrintFriendly sharing feature.
Are there any fees associated with using this form?
There are no fees for using the Network Exception Request Form, but verify with your provider for any additional costs.
What information do I need before filling out the form?
Gather all necessary information, including patient details and provider credentials, to complete the form accurately.
How quickly will I get a response after submission?
Response times may vary; please allow adequate time for processing after your submission.
What if I have questions about the form while filling it out?
You can contact customer support at 1.877.279.7603 for any inquiries.
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