FORMS FOR PROVIDERS
Medical Prior Authorization
Our new Utilization Management (UM) partner offers different forms for each type of Prior Authorization you may request in order to get the most specific and efficient information. If your patient’s service is not listed, you may use the 2021 General Medical Prior Authorization Form listed below.
- Autologous Cultured Chondrocytes
- Breast Reconstruction
- Eyelid and Brow Repair (Blepharoplasty)
- Genetic testing
- Hyaluronic Acid Derivatives
- Infuse Bone Graft
- Pharmaceuticals Unclassified Medical Benefit Drug
- Port Wine Stain – Abnormal Vascular Lesion Treatment
- Reduction Mammoplasty
- Skin substitute
- Spinal Cord Stimulator
- Transgender Services
- Vagus Nerve Stimulation
- 2021 General Medical Prior Authorization Form
Prescription Prior Authorization
Please submit completed prescription authorization requests via phone by calling 1.800.711.4555, electronically through go.covermymeds.com/OptumRx .
NOTE: When submitting an authorization request, it is important to use Drug Specific forms when applicable. Please use the most up-to-date forms on OptumRx’s website and be sure to include all of the relevant information. If a submitted request is missing information the request(s) can be delayed or denied due to lack of information. Please check for the drug specific form because the use of out dated or general forms may not contain all required elements and could result in a delay or denial of the authorization request.
If there are not any in-network providers that can provide a medically necessary service, in-network providers may submit a written referral for a member to see an out-of-network provider. The referral request will be reviewed by CGHC.
Please note, referrals are only considered in rare circumstances and are generally NOT necessary for the following services:
- Emergency Care
- Urgent Care
- Maternity care for new members in 3rd trimester of pregnancy (prior authorization is required)
- Full-time students enrolled in Institutes of Higher Learning seeking behavioral health or substance abuse disorder treatment outside of CGHC’s services area but within the state of Wisconsin.
* Please note follow-up care is not covered at out-of-network facilities.