Medical, surgical and device authorization forms
Select your provider type in order to view applicable authorization forms.
Contracted providers (in-network providers)
Our Auth Request tool has two portals, GuidingCare and eviCore. In-network providers should submit all authorizations through our Auth Request tool with the exception of NICU/sick newborn authorization form, Solid organ transplant authorization form, or Bone marrow/stem cell transplant authorization form. Turnaround times vary by plan requirements, but in all cases are 14 days or less.
Our Auth Request tool will use GuidingCare to process your authorization requests for:
- Post-acute facilities
- Behavioral health
- Durable medical equipment (DME)
- Home health care
- Planned surgeries and procedures
Our Auth Request tool will use eviCore to process your authorization requests for:
- High-tech imaging
- Spine surgery
- Joint surgery
- Lab and genetic services
Non-contracted providers (out-of-network providers)
Out-of-network providers: Use these forms to request prior authorization for medical services. Always use a specific service form when available. Turnaround times vary by plan requirements, but in all cases are 14 days or less.
Hospital and other facility forms
- Emergent inpatient 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. Do not use this form for elective/planned inpatient admissions, instead use the Medical Authorization Form. If we determine your request does not meet the definition of an emergent authorization it will be processed according to standard timelines.
All emergent cases are reviewed in 72 hrs or less.
- NICU/Sick newborn prior authorization form
- Acute Rehab/LTACH/SNF/SAR prior authorization/review form
Use this form for all post-acute facility requests.
- Bone marrow/peripheral stem cell or other blood cell transplant
- Solid organ transplant
Behavioral health authorization forms
- General behavioral health authorization form - Use this form for: psychiatric inpatient, outpatient psychotherapy (mental health and substance abuse), detoxification, residential treatment and other behavioral health services.
- Applied Behavioral Analysis (ABA) therapy authorization request form
- Transcranial Magnetic Stimulation (TMS) for depression authorization request
Home health care services forms
- Home health care services prior authorization form
- Home health care IV infusion services prior authorization form
Other medical authorization forms
- Clinical trials prior authorization form
- DME/P&O prior authorization form
- Medical prior authorization form