Provider Toolkit: Prior Authorization Guide

How to Secure Prior Authorization

Pre-Auth Needed Tool

Use the Pre-Auth Needed Tool on to quickly determine if a service or procedure requires prior authorization.

Submit Prior Authorization

If a service requires authorization, submit via one of the following ways:

Provider Portal
This is the preferred and fastest method.

After normal business hours and on holidays, calls are directed to the plan’s 24-hour nurse advice line. Notification of authorization will be returned by phone, fax or web.


  • Medical Prior Authorization Fax: 833-603-2871
  • Medical Inpatient Admissions Fax: 833-751-2724
  • Medical Concurrent Review Fax: 833-751-2721
  • Behavioral Health Inpatient Fax: 833-792-2721
  • Better Health Outpatient Fax: 833-792-2720
  • High Tech Imaging:
  • Rehabilitation Services and Pain Management:
  • Pharmacy - Envolve Pharmacy Solutions prior authorization can be accessed at under the "CoverMyMeds" link

Timeframes for Prior Authorization Requests and Notifications

The following timeframes are required of the ordering provider for prior authorization and notification:

Service TypeTimeframe
Schedule admissions5 business days prior
Elective outpatient services5 business days prior
Emergent inpatient admissions1 business day
Observation - 48 hours or less1 business day for non-participating providers
Observation - greater than 48 hours1 business day
Maternity admissions1 business day
Newborn admissions1 business day
Neonatal Intensive Care Unit (NICU) admissions1 business day
Outpatient Dialysis1 business day
Organ transplant initial evaluation30 days prior
Clinical trials services30 days prior


See below for a list of services that require prior authorization.


Please note:

  1. Emergency services DO NOT require prior authorization.
  2. All out-of-network services and providers DO require prior authorization.
  3. Failure to complete the required authorization or notification may result in a denied claim.

Services and Procedures Requiring Prior Authorization


Ancillary Services


Inpatient Admissions

  • Air ambulance transport (non-emergent fixed wing airplane)
  • Durable Medical Equipment (DME)
  • Home healthcare services
  • Hospice
  • Furnished medical supplies
  • Orthotics/prosthetics
  • Genetic testing
  • Quantitative urine drug screen
  • Outpatient Physical, SPeech and Occupational therapy administered by NIA*
  • Experimental or investigational
  • High Tech Imaging administered by NIA
  • Cardiac and respiratory therapy
  • Observation stays exceeding 48 hours 
    • Notification is required within 1 business day if admitted
  • Transplants
  • Partial inpatient, PRTF and/or intensive outpatient programs

*Effective for dates of service on or after January 1, 2022


Provider Portal

Out-of-Network Services

All out-of-network services and providers require prior authorization, excluding emergency services.