OAR 836-053-1205: Exhibit 1, Uniform Prior Authorization Prescription Request, form (440-4992)

In this section you will find the tools and resources you need to help manage your practice’s prior authorization and notification requirements, with program specific information available for Cardiology, Oncology, Radiology, Clinical Pharmacy and...

Advance notification is the first step in UnitedHealthcare’s process to determine coverage for a member. Certain services and plans require advance notification so we can determine if they are medically necessary and covered by the member’s plan.

Prior Authorization Fax Form

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Nebraska Community Plan care providers.

Please send this request to the issuer from whom you are seeking authorization. Do not send this form to the Texas Department of Insurance, the Texas Health and Human Services Commission, or the patient’s or subscriber’s employer.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Mississippi Community Plan care providers.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Arizona Community Plan care providers.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Hawaii Community Plan care providers.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Maryland Community Plan care providers.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Michigan Community Plan care providers.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of New Jersey Community Plan care providers.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of New York Community Plan care providers.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Ohio Community Plan care providers.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Pennsylvania Community Plan care providers.

These paper fax forms are meant to be used in requesting prior authorizations for specific drugs for the state of Rhode Island Community Plan care providers.