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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 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.
  • 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