Members & Providers
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
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