Authorizations for out-of-network providers

We require prior authorization for certain services and procedures. In these cases, providers will submit clinical documentation and medical records demonstrating that the service or procedure is medically necessary.

How to request an authorization

Use the forms below to request prior authorization for medical services. Always use a specific service form when available. Turnaround times vary by plan requirements, but all cases are 14 days or less.

Outpatient, elective/planned inpatient admissions

• Medical prior authorization form
  Before using this form, review the prior authorization forms below to determine whether there’s a specific service form available for your request.
• Clinical trials prior authorization form
• DME/P&O prior authorization form

Hospital and other facility

• Acute Rehab/LTACH/SNF/SAR prior authorization/review form
  Use this form for all post-acute facility requests. Note: We’ve updated this form. Effective May 22, 2022, we will only accept this new form. Old forms will be returned via fax as they don’t have all the necessary information.
• Bone marrow/peripheral stem cell or other blood cell transplant prior authorization form
• Emergent inpatient prior authorization form
  A request is considered emergent if delaying treatment would put the patient’s life in serious danger, interfere with full recovery or delay treatment for severe pain. Don’t use this form for elective/planned inpatient admissions, instead use the Medical Prior Authorization Form. If we determine your request doesn’t meet the definition of an emergent authorization, it will be processed according to standard timelines. All emergent cases are reviewed in 72 hours or less.
• NICU/sick newborn prior authorization form
• Solid organ transplant prior authorization form

Behavioral health

• Applied Behavioral Health (ABA) therapy prior authorization form
• Behavioral health prior authorization form
  Use this form for psychiatric inpatient, outpatient psychotherapy (mental health and substance abuse), detoxification, residential treatment and other behavioral health services.
• Transcranial Magnetic Stimulation (TMS) for depression prior authorization form

Home health care services

• Home health care services prior authorization form
• Home health care IV infusion services prior authorization form

How to check your authorization status

1. Log into your prism account
2. Open the Authorizations menu
3. Click Check Auth Status

Don't have a prism account? Contact Provider Services for help checking the status of your authorization request.

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