1. Introduction
2. Patient Information
3. Service Information
4. Service Details
5. Provider Information
6. Facility Information
7. Summary
8. Submission
9. 
   Return to Main

Precertification Request Form

If you have an urgent/emergent case please call 866-415-6175.

Please have the following information available before you begin:

• Member Identification number
• Patient’s full name, address, and phone number
• Diagnosis code(s)
• CPT codes (if applicable)
• Admitting/Ordering physician’s full name, address, phone number and tax ID
• Facility name, address, phone number and tax ID

If additional information is needed to complete the review, you will be contacted. After the review has been completed, you will be contacted regarding the outcome of your request.