Providers
Prior authorization for requested services
The primary coverage criteria of certain services must be established through a Prior Approval or pre-authorization process before they can be performed. Please refer to Availity Essentials portal, Health Advantage Coverage Policy or the member's benefit certificate to determine which services need prior approval.
Important information
- This form should only be used for Health Advantage members, including members of ASE/PSE.
What to include with the completed Authorization | Organizational Determination Request Form [pdf]
Please fill out the form in its entirety and include all relevant clinical documentation to support the request.
Prior Authorization Code Lookup
Our tool is currently under construction.