Forms

Form must be completed to enroll in EFT. EFT forms are also available to submit through the secure provider portal.

Enrollment / Change / Cancellation

 

ERA forms are also available to submit through the secure provider portal.

Enrollment / Change / Cancellation

Prior authorization is the review of the medical necessity and appropriateness of selected health services before they are provided. Annual review of prior authorization criteria was completed on 1/14/2020.

Refer to the provider manual for more information regarding the prior authorization process.

 

Tips for requesting authorizations:

  • ALWAYS verify member eligibility prior to providing services
  • Complete all entire form and attach supporting documentation prior to submitting
  • Submit the request timely to ensure Prior Authorization staff have 3 business days to complete the review

Remember, a request for prior authorization is not a guarantee of payment. Unauthorized services will not be reimbursed.

To request an authorization, find out what services require authorization or check on the status of an authorization, visit our provider secure web portal. For more information about prior authorization, review your provider manual.