Requesting Prior Authorization or Coordinating a PCP Referral

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

To request prior authorization or coordinate a primary care physician (PCP) referral for services other than advanced imaging services and cardiac imaging:

The PCP or specialist must give the Medical Management Department as much advance notice as possible when requesting prior authorization. For elective inpatient or outpatient services, fax requests for prior authorization at least five days before the anticipated date of service. It is recommended not to schedule services prior to receiving the review decision. The Medical Management Department needs time to notify the provider of the review decision prior to the services being rendered.

Required Information

Submit the following information when requesting prior authorization:

  • Member's name
  • Member's identification number
  • Member's date of birth
  • Diagnosis
  • Requesting physician's name, address, phone and fax numbers, and contact person
  • Place where services are provided
  • Physician's name (physician receiving referral), ancillary provider name and facility name
  • Procedures
  • Date of service

The Medical Management Department reviews the information and calls back with the review decision. If the service is authorized, an authorization number is given.

Submission of Prior Authorization Requests

Fax the prior authorization form to the Medical Management Department. Use the fax number on the form to submit requests 24 hours a day, seven days a week.