How to Submit Prior Authorization Requests

For Prior Authorization requests covered by Well Sense Health Plan, see below.

For Pharmacy Prior Authorization forms visit Pharmacy Prior Authorization.

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Recheck fax numbers before sending.

Method Instructions Phone Fax/Email

Fax Medical Prior Authorization Request Form

Please attach supporting clinical information with all requests. If you have any questions about this form, please contact the Provider Service Center. 877-957-1300

Fax: 603-218-6634 

Submit Prior Authorization Requests Online Request a login to our Prior Authorization request system.

If you already have a login, please log in here.

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

Service Partner Phone Fax Web or Email
Behavioral Health Beacon Health Strategies 866-444-5155 N/A Website
Durable Medical Equipment Northwood, Inc 866-802-6471 877-552-6551 Website
Outpatient Radiology eviCore healthcare (formerly MedSolutions) 888-693-3211 888-693-3210 Website
Non-emergency Transportation Well Sense Transportation Line 844-909-7433 N/A Website
Vision Services Vision Services Plan (VSP) 800-877-7195 N/A Website