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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