How to Submit Prior Authorization Requests

For Medical Prior Authorization requests, see below. For Pharmacy Prior Authorization requests, visit Pharmacy Prior Authorization.

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Protect PHI.
 Please double check fax numbers before sending.

Method Instructions Contact
Submit Online Log in to our provider portal to submit your prior authorization request online.

For Medicaid Questions

For Medicare Questions

Submit by Fax

Please attach supporting clinical information with all requests. If you have any questions about this form, please contact the Provider Service Center.

Submit for Medicaid member
Submit for Medicare Advantage member

Medicaid Fax:

Medicare Fax:

For behavioral health, durable medical equipment, radiology services, or non-emergency transportation, please contact our partners.

Service Partner Contact
Behavioral Health Beacon Health Strategies Phone: 866-444-5155
Durable Medical Equipment Northwood, Inc. Phone: 866-802-6471
Fax: 877-552-6551
Outpatient Radiology evicore healthcare

Phone: 888-693-3211
Fax: 888-693-3210

Non-emergency Transportation Well Sense Transportation
Phone: 844-909-7433 (Medicaid)
Phone: 844-458-6226 (Medicare Advantage)
Vision Services Vision Services Plan (VSP) Phone: 800-877-7195 (Medicaid)
Phone: 855-492-9028 (Medicare Advantage)
Dental Services DentaQuest Phone: (833) 955-336 (Medicare Advantage)