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Authorizations
Search for Required Medical Services-Request Authorization Page Tab Content
GLO-PRV-Search Authorization Page-Row 1 Content
The medical services including provider administered drugs below require prior review by the plan to determine clinical medical necessity.
Authorization - Preauthorization - Basic Web Content
Referral & Authorization Guidelines
- Prior Authorization Guidelines Code List - July 1, 2019Open a PDF
- Prior Authorization Guidelines Code List - February 28, 2019Open a PDF
- DME Prior Authorization List - July 1, 2019Open a PDF
- UM Initial Determination Timeframes - Commercial ProductsOpen a PDF
- UM Initial Determination Timeframes - Medicare ProductsOpen a PDF
- UM Initial Determination Timeframes - Medicaid & Safety Net ProductsOpen a PDF
- Behavioral Health Prior Authorization Guidelines Code List Effective July 1, 2019Open a PDF
- eviCore Codes Requiring Preauthorization - Master GridOpen a PDF
- Sleep Management Program Updates
- Medical Specialty Drug (For Commercial, Exchange and Medicare)Open a PDF
Univera Healthcare MyHealthSM, Child Health Plus and MyHealth PlusSM
- Inpatient Prior Authorization FormOpen a PDF
- Outpatient Prior Authorization FormOpen a PDF
- Adult Behavioral Health Home and Community Based Services Prior/Continuing Authorization FormOpen a PDF
- Behavioral Health Outpatient Treatment Request FormOpen a PDF
- Inpatient and Outpatient Neuropsychological and Psychological Testing Authorization FormOpen a PDF
- Behavioral Health Prior Authorization Guidelines Code List Effective July 1, 2019Open a PDF
- Sleep Management Program Updates
- Medical Specialty Drug (For Medicaid and Child Health Plus)Open a PDF
