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Medicare Pre-Auth

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All attempts are made to provide the most current information on the Pre-Auth Needed Tool. However, this does NOT guarantee payment. Payment of claims is dependent upon eligibility covered benefits, provider contracts and correct coding and billing practices. For specific details, please refer to the Medicare Advantage provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.

We have separate fax numbers for Medicaid and Medicare pre-authorizations. Please make sure you use the correct fax number to expedite your request. Medicare FAX: 1-877-687-1183. If your request is for a Medicaid recipient, please use this number: Medicaid FAX: 1-866-467-1316.


All Out of Network requests require prior authorization except emergency care, out-of-area urgent care or out-of-area dialysis. Please use the forms below to request prior authorizations.


Medical Forms

Medicare Inpatient Prior Authorization Request Form (PDF)

Medicare Outpatient Prior Authorization Request Form (PDF)

Request for Medicare Prescription Drug Coverage Determination form (PDF)

Requesting Electronic Prescription Drug Prior Authorization Using CoverMyMeds® (PDF)


Behavioral Health Forms

Medicare Outpatient Treatment Request Form (PDF)

Medicare Electroconvulsive Therapy (ECT) Authorization Request Form (PDF)

Medicare Neuropsych Testing Authorization Request Form (PDF)

Medicare Outpatient Psychological Testing Authorization Request Form (PDF)


View a list of services that require prior authorization (PDF). View a list of Part B Drugs that require prior authorization (PDF).


Are Services being performed in the Emergency Department or Urgent Care Center, or are the services for dialysis or Hospice?

Types of Services YES NO
Is the member being admitted to an inpatient facility?
Are anesthesia services being requested for pain management, dental surgery or services in the office rendered by a non-participating provider?
Is this an HMO Out of Network service request?