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

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

• Medication Prior Authorization Request Form - CO Opens as PDF

Florida

• Prior Authorization Form Opens as PDF

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

Indiana

• Indiana - Prior Authorization Form 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

Maryland

• Uniform Treatment Plan Form—Mental Health and Substance Use Opens as PDF

Michigan

• Request for External Review Form - MI Opens as PDF
• Physician Certification for E&I External Review - MI Opens as PDF

Mississippi

• External Review Application Opens as PDF

New Hampshire

• Medication Prior Authorization Form - NH Opens as PDF

New Jersey

• Provider Complaint Form Opens as PDF
• External Appeal Request Forms Opens as PDF

New York

• External Appeal Instructions Opens as PDF
• External Appeal Application Opens as PDF

Ohio

• External Review Request Forms Opens as PDF

Oklahoma

• Precertification Request Form for Prescription Medications Opens as PDF

Oregon

• Uniform Prior Auth. Prescription Request Form Opens as PDF

South Carolina

• External Review Information and Forms 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 Form

Virginia Physician Cert for Expedited ER Form

Virginia Physician Cert for E&I Form

Virginia Appointment of Auth Representative Form