Alaska
- Physician Certification Expedited External Review Request FormOpens as PDF
- Physician Certification Standard Experimental and Investigational External Review Request FormOpens as PDF
- Physician Certification Standard External Review Request Form Opens as PDF
- External Review Request FormOpens as PDF
- Physician Certification Expedited Experimental and Investigational External Review Request FormOpens as PDF
Arkansas
- Precertification Request Form for Prescription Medications Opens as PDF
- Arkansas UM statistics Opens as PDF
- External Review Request Form Opens as PDF
- Physician Experimental & Investigational External Review Form Opens as PDF
- Physician Expedited External Review Request Form Opens as PDF
- Guidelines and Review Criteria Opens as PDF
Arizona
- Prior Auth Request Form – Health Care Services Opens as PDF
- Prior Auth Request Form – Medications and DME Opens as PDF
- Appeal Request Form Opens as PDF
- External Review Request Form Opens as PDF
- Provider Cert for Expedited Reviews Opens as PDF
- Appeal information for Boon Group members: https://www.aetna.com/health-care-professionals/disputes-appeals/disputes-appeals-overview.html
California
- Prescription Drug Prior Authorization or Step Therapy Exception Request Form Opens as PDF
- California Independent Medical Review Application Opens as PDF
- Experimental and Investigational Physician Certification Form Opens as PDF
Colorado
Connecticut
Florida
Georgia
Illinois
- Precertification Request Form for Prescription Medications Opens as PDF
- External Review Request Form – IL Opens as PDF
- Physician Certification for E&I External Review – IL Opens as PDF
- Physician Certification for Expedited External Review – IL Opens as PDF
- Illinois UM Pre-Cert Statistics 2020 Opens as PDF
- Illinois UM Pre-Cert Statistics 2021 Opens as PDF
- Illinois UM Pre-Cert Statistics 2022 Opens as PDF
- Illinois UM Pre-Cert Statistics 2023 Opens as PDF
Indiana
Kentucky
Nippon member portal (Nippon Life Benefits groups only)
Massachusetts
- Behavioral Health LOC Request Form Opens as PDF
- Cardiac Imaging Prior Auth Form Opens as PDF
- CT, CTA, MRI, MRA Prior Auth Form Opens as PDF
- Hep C Medication Prior Auth Form Opens as PDF
- Non-OB Ultrasound Prior Auth Form Opens as PDF
- PET – PET CT Prior Auth Form Opens as PDF
- Psych and Neuropsych Assessment Supplemental Form Opens as PDF
- Repetitive Transcranial Magnetic Stimulation Request Form Opens as PDF
- Standard Medication Prior Auth Form Opens as PDF
- Synagis Prior Auth Form Opens as PDF
- External Review Request Form Opens as PDF
If you need assistance or have questions, the Massachusetts Health Policy Commission may be able to assist you by contacting:
Massachusetts Health Policy Commission
Office of Patient Protection
50 Milk Street
Boston MA 02109
800-436-7757 (phone)
1-617-624-5046 (fax)
Maryland
Michigan
- Request for External Review Form – MI Opens as PDF
- Physician Certification for E&I External Review – MI Opens as PDF
Mississippi
New Hampshire
New Jersey
New Mexico
New York
- External Appeal Instructions Opens as PDF
- External Appeal Application Opens as PDF
- Behavioral Health Admission Notification Form Opens as PDF
- Form to designate a representative Opens as PDF
Ohio
Oklahoma
Oregon
South Carolina
Tennessee
- Utilization Management Program (Nippon Life Benefits groups only) Opens as PDF
- Grievance Program (Nippon Life Benefits groups only) Opens as PDF
- External Review (Nippon Life Benefits groups only) Opens as PDF
Texas
- Health Services Prior Authorization Form Opens as PDF
- TX Independent Review Request Form—English Opens as PDF
- TX Independent Review Request Form—Spanish Opens as PDF
- Medication or DME Uniform Prior Authorization Form Opens as PDF
Virginia
- Virginia External Review FormOpens as PDF
- Virginia Physician Cert for Expedited ER FormOpens as PDF
- Virginia Physician Cert for E&I FormOpens as PDF
- Virginia Appointment of Auth Representative FormOpens as PDF