Sometimes you’ll need to get approval before providing certain services to your patients. The requirements and processes for authorization differ based on your patients’ coverage plans, which are outlined below.
Prior authorization is required for certain procedures, services and medications, as well as for all inpatient admissions. The requirements and processes for authorization differ based on your patients’ coverage plans. For detailed information, please see the Provider Administration Manual related to their coverage.
The programs listed below have specific prior authorization requirements.
Non-emergent air transport requires prior authorization. Please call Alacura directly at 1-877-561-22871-877-561-2287 or fax to 1-877-561-46641-877-561-4664. Calls and faxes are accepted 24/7.
You can verify benefits and request prior authorization at Availity.com, by phone at 1-800-924-71411-800-924-7141 or fax to 1-866-558-0789.
You can verify benefits and request prior authorization at Availity.com, by phone at 1-800-924-71411-800-924-7141 or fax to 1-866-558-0789.
This includes: CT, CTA, MRI, MRA, MRS, Nuclear Cardiac, PET and CPT. You can verify benefits and request prior authorization at Availity.com or by phone at 1-800-924-71411-800-924-7141 or fax at 1-866-558-0789.
Musculoskeletal prior authorization is required for spinal surgery, joint surgery (hip, knee and shoulder) and pain management. You can request prior authorization at Availity.com or by fax at 1-866-747-0587.
Prior authorization is required for sleep studies performed in a lab setting for adults 18 years or older. Prior authorization isn’t required for sleep studies performed at home. This program applies to fully-insured members and is an optional add-on for Administrative Services Only (ASO). You can verify benefits and request prior authorization at Availity.com anytime day or night OR fax completed form to Commercial Utilization Management at 1-866-558-07891-866-558-0789. If you have an urgent review and you need an immediate response, please call 1-800-924-71411-800-924-7141.
Provider Reference Guide/Prior Authorization List
Master Prior Authorization List
Master Prior Authorization List Code Removals
The programs listed below have specific prior authorization requirements.
We’re committed to providing quality and cost effective health care services to our members. Our decisions are based only on existence of coverage and appropriateness of care.
Before beginning the reconsideration and appeals process, treating providers can request a Peer-to-Peer discussion with a doctor to review details of the member’s condition and care options.
Expedited Appeals are available for members who are at a more urgent risk for severe health issues without the previously requested care or service. You can request an expedited appeal by calling the prior authorization number for the plan that covers your patient.
If you disagree with a decision we’ve made or if you need to provide additional information that may affect the decision, please submit a Provider Reconsideration Form to us within 18 months of the initial denial.
You may file a formal appeal by submitting a Provider Appeals Form to us. Please see this helpful guide with timelines for each line of business. If the reconsideration stated that the reconsideration decision was related to medical necessity, you may be directed to the Commercial Utilization Management Appeal Form.
You have the option to request binding arbitration if you’re not satisfied with the formal appeal decision. Please see the Provider Dispute Resolution Procedure or the Provider Administration Manual based on the plan that covers your patient.
Commercial Prior Authorization List
Federal Employee Predetermination / Prior Approval Form
Provider Attestation for Abortion Services
Provider Attestation Form for Gender-Affirming Services
Air Ambulance
Radiation Oncology Therapy Authorization Codes
High Tech Imaging Authorization Codes
High-Tech Imaging Prior Authorization Workflow
Musculoskeletal Procedure/Pain Management Codes
Epidural Steroid Injection Authorization Request
Facet Joint Injection Authorization Request
Joint and Spine Authorization Request
Neurotomy Authorization Request
Commercial Lab Sleep CPT Code List
Commercial Lab Sleep Study Form
High Tech Imaging Codes Requiring Authorization
High Tech Imaging C Code Crosswalk Reference Guide
Medicare Advantage Provider-Administered Part-B Specialty Drug List
High Tech Imaging codes Requiring Authorization
High Tech Imaging C Code Crosswalk Reference Guide
Outpatient Musculoskeletal Procedure Codes Requiring Authorization
Potential Cosmetic Investigational or Non Covered Procedure Code List
Prescription Drug Coverage determination Request
BlueCare Plus Provider-Administered Specialty Drug List
Care Management Contact Information
Advance Determination Decision
Advance Determination Request
Durable Medical Equipment Request
Home Health Request
Home Infusion Therapy Request
Inpatient/Outpatient Services Request Form
Inpatient Rehabilitation Request
Medical Psychiatric Inpatient Request
Observation Notification Request
Out of Network (OON) Benefits Request
Outpatient Therapy Request
Part B Specialty Pharmacy Drug Request
Prescription Drug Coverage determination Request
Psychological Testing Authorization Request
Skilled Nursing Facility Request
Reconsideration Process Map
Appeals Process Map