Prior Authorization Requirements

Prior authorization tool

To request or check the status of a prior authorization request or decision, access our Interactive Care Reviewer (ICR) tool via Availity. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate.

Physical Health

If you are unable to submit the request online through the Availity Portal, please download and complete the Prior Authorization Form, then fax your request to 1-800-964-3627.

Behavioral Health

Services billed with the following revenue codes always require prior authorization:

• 0240–0249 — All-inclusive ancillary psychiatric
• 0901, 0905–0907, 0913, 0917 — Behavioral health treatment service
• 0944–0945 — Other therapeutic services
• 0961 — Psychiatric professional fees

If you are unable to submit the request online through the Availity Portal, please fax requests to:
Inpatient — 1-877-434-7578
Outpatient — 1-866-877-5229

Pharmacy

Check out our Preferred Drug List (PDL).

Services billed with the following revenue code(s) always require prior authorization:
0632 — Pharmacy multiple sources

Long-term services and supports

Providers needing an authorization should call 1-877-440-3738.

The following always require prior authorization:

Elective services provided by or arranged at nonparticipating facilities

All services billed with the following revenue codes:
0023 — Home health prospective payment system
0570–0572, 0579 — Home health aide
0944–0945 — Other therapeutic services
3101–3109 — Adult day and foster care

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