Prior Authorization Forms
The PA department has changed the Prior Authorization Request Form for DME, DMS, and Outpatient Procedures to include some critical information that will assist in the proper and accurate entry of an authorization request.
We hope these changes will make the form easier to use and will lead to better completion with less phone calls to determine incorrect or missing information. Use the forms here to submit a prior authorization request.
Outpatient PA Form Inpatient PA Form
Prior Authorization Specific Listing
Current PA Specific Listing/pdf Current PA Specific Listing/excel
The PDF can be searched using the F5 option and the excel version of this document can be filtered by category, code, or description.
The Prior Authorization Department has added new codes:
*Effective 2/15/23, the following codes will be added to the list requiring PA:
A2014, A2015, A2016, A2017, A2018, A4596, C9098, E0183, J0739, J1302, J1306, J1551, J1932. J2356, J2777, J2779, J2998, J3299, J9274, J9298, J9331, J9332, Q2056, T1032, T1033
And removing the PA requirements for:
92603, 92604, 92626, 81420, 92610, 92611, 76801, 95700, 93241-93248, V2623, V2624, V2625, V2626
(Please be aware that the current pdf and excel linked above do not include these updates, but we are working diligently to publish them as quickly as possible.)
These forms and other provider documents can be found under Provider Documents.
Please reach out to the Prior Authorization Department with questions by calling 1-855-839-1032 or emailing firstname.lastname@example.org.