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Prior approval 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 AHIN, 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.
- Providers requesting a prior approval for Walmart or other BlueAdvantage members should use the appropriate form from the BlueAdvantage website.
What to include with the completed Prior Approval Form [pdf]
- Member Information
- Requested service(s)
- Name and telephone number of contact person
- Fax number to send determination
- Requesting / Performing Provider’s NPI or Provider ID
- Copy of member’s insurance card (front/back)
- Other Insurance Information
- CPT Code(s), ICD 10/HCPCS Code(s), Modifiers that are applicable
- Please use the most descriptive procedure and diagnosis codes
- Medical records to support requested services