Prior Authorization Forms

General Prior Authorization Forms

Medical Necessity Supporting Documentation

Some prior authorization requests require documentation in addition to the prior authorization form to support a determination of medical necessity.  To see which documentation is necessary for a prior authorization request, go to:

Submitting Additional Supporting Documentation

If a prior authorization request lacks the necessary information to determine medical necessity, we will send a letter describing the documentation that needs to be submitted to the member and the requesting provider within 3 business days from receipt of the request. The notification will include applicable timeframes for the provider to submit the requested information.

When possible, we will also contact the requesting provider by telephone to obtain the information necessary to complete the prior authorization process.

If the information is not provided within 3 business days of our request for additional information, the request may be denied. A preemptive physician review between our medical director and the requesting physician will occur before the request is denied.

If we receive the requested information, we will review the request within 3 business days.

Please fax prior authorization requests and supporting documentation to 877-940-1972.