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.
Protect PHI. Recheck fax numbers before sending.
|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
|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|