Our Utilization Management team is responsible for receiving, processing and responding to your prior authorization requests. These decisions are based on care and service relevance and benefit coverage existence. Procedures are followed based on a Member’s medical necessity. This reduces administrative barriers for doctors and other providers. All inpatient and outpatient requests and notifications must include your NPI number for proper processing of your claim.
Select the links to download the following forms to submit via fax:
- Out Patient Prior Authorization Request
- In Patient Prior Authorization Request
- Behavioral Health Prior Authorization Request
- BioPharmacy Coverage Determination Request
- Medical Records – Fax Submissions at 844.303.2643
|Prior Authorization Request Fax Numbers|
|844-776-1664 – Inpatient/Outpatient Prior Auth.||844-895-2705 – Inpatient Concurrent Review|
|844-318-9183 – Behavioral Health||844-303-2643 – Medical Records|
|833-231-2304 – LTSS Service Plan Requests||800-424-4833 – Imaging / Radiology|
|844-776-1664 -BioPharmacy Coverage Determination|
NextLevel Health Prior Authorization Process:
Effective on January 1, 2018, decisions for all urgent prior authorization requests will be made within 48 hours or two (2) calendar days. Non-urgent requests will be made within 4 calendar days from receipt of request.