In order to initiate a prior authorization request, the following essential information (EI) is required:
Member number or Medicaid number
Member date of birth
Requesting provider’s name
Requesting provider’s National Provider Identifier (NPI)
Rendering provider’s Name
Rendering Provider’s National Provider Identifier (NPI)
Rendering Provider’s Tax Identification Number (TIN)
Service requested – use Current Procedural Terminology (CPT) Healthcare Common Procedure Coding System (HCPCS), or Current Dental Terminology (CDT), as appropriate
Service requested start and end dates
Quantity of service units requested based on the CPT, HCPCS, or CDT requested
If a prior authorization request does not contain each of the essential information data points, the request will not be created and will be returned to the provider with guidance on which information is missing.
NOTE: Please ensure all required clinical documentation is included to avoid delays in service for our shared members.