Authorizations & Appeals

Request prior authorization and submit appeals

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.

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PROVIDER ADMINISTRATION MANUAL

Prior Authorization Information

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.

Prior Authorization Requests

You can submit prior authorization requests for all lines of business 24/7 at Availity.com

LAUNCH AVAILITY

Authorizations & Appeals

Review services that require special approval

Commercial
Upcoming Prior Authorization Changes
New Commercial Prior Authorization Process
Commercial Prior Authorization List
Federal Employee Predetermination / Prior Approval Form
Provider Attestation for Abortion Services
Provider Attestation Form for Gender-Affirming Services
Program Specific Prior Authorization
The programs listed below have specific prior authorization requirements.
Radiation Oncology
You can verify benefits and request prior authorization at Availity.com, by phone at 1-800-924-7141 or fax to 1-866-558-0789.
Radiation Oncology Therapy Authorization Codes
Genetic Testing
You can verify benefits and request prior authorization at Availity.com, by phone at 1-800-924-7141 or fax to 1-866-558-0789.

High Tech Imaging
This includes: CT, CTA, MRI, MRA, MRS, Nuclear Cardiac, PET and CPT. You can verify benefits and request prior authorization at Availity.com, by phone at 1-800-924-7141 or by fax at (570) 595-4311.
High Tech Imaging Authorization Codes
High Tech Imaging Authorization Request Form
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Musculoskeletal
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.
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Musculoskeletal Procedure/Pain Management Codes
Epidural Steroid Injection Authorization Request
Facet Joint Injection Authorization Request
Joint and Spine Authorization Request
Neurotomy Authorization Request
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Commercial Lab-based Sleep Study
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 1-866-558-0789. If you have an urgent review and you need an immediate response, please call 1-800-924-7141.
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Commercial Lab Sleep CPT Code List
Commercial Lab Sleep Study Form
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Medicare Advantage
Provider Reference Guide/Prior Authorization List
Master Prior Authorization List
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Program Specific Prior Authorization
The programs listed below have specific prior authorization requirements.
Pharmacy
Medicare Advantage Provider-Administered Part-B Specialty Drug List
CMS Inpatient Only List
CMS Inpatient Only List
Outpatient Observation
Medicare OutPatient Observation Notice
BlueCare Plus - Medicare and Medicaid Dual Eligible
Centers for Medicare & Medicaid Services Authorization Information

Centers for Medicare & Medicaid Services (CMS) Reports
National Coverage Determinations(NCDs) Alphabetical Index Database
National Coverage Determinations Manual
Self-Administered Drug List
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High Tech Imaging
High Tech Imaging C Code Crosswalk Reference Guide
Musculoskeletal
Outpatient Musculoskeletal Procedure Codes Requiring Authorization
Pharmacy
Prescription Drug Coverage Determination Request
BlueCare Plus Provider-Administered Specialty Drug List
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Utilization Management Resources
Care Management Contact Information
Forms
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
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AUTHORIZATION POLICIES AND PROCESS

Authorization Appeals Process

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.

Parts of Our Authorization Appeals Process

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Looking for more information?

Find the details in our Utilization Management Guidelines.

SEARCH GUIDELINES

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Authorizations & Appeals

PROVIDER ADMINISTRATION MANUAL

Prior Authorization Requests

Authorizations & Appeals

Commercial

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Medicare Advantage

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BlueCare Plus - Medicare and Medicaid Dual Eligible

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AUTHORIZATION POLICIES AND PROCESS

Parts of Our Authorization Appeals Process

Request a Reconsideration

Appeal the Reconsideration

Request Arbitration

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Looking for more information?

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AUTHORIZATION POLICIES AND PROCESS

Parts of Our Authorization Appeals Process

Request a Reconsideration

Appeal the Reconsideration

Request Arbitration

Looking for more information?

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