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
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
Connecticut
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
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
- Chemo and Supportive Care Prior Auth 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)
http://www.mass.gov/anf/budget-taxes-and-procurement/oversight-agencies/health-policy-commissio
n/patient-protection/