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 1-844-462-0022 .

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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