Prior Authorizations

**Expedited Request: By selecting expedited request, you are implying that following a standard timeframe could seriously jeopardize this members’ life or health. (A retro request is not an expedited request).

Utilization Management FAQs

Authorization Grid

Physical Health

• Home Health Authorization Form
• Hospice Authorization Form
• Hospital Length Of Stay Authorization Form
• Prior Authorization Service Request
• Rick’s Medical Supply DME Prescription Form

• HEP C: (Only required for treatment naive)
  • Hepatitis C Care and Readiness to Treat Checklist
  • Hepatitis C Direct-Acting Antivirals FFS Drug Use Criteria
  • MedImpact Specialty Medication Referral Form
  • Child-Turcotte-Pugh Calculator
• Bariatric Surgery:
  • Bariatric Phase 1 is no longer required for Bariatric Surgery. Referral to local surgeon does not require a prior authorization. Please review the Bariatric Surgery Readiness Checklist Form and OHP Guideline 8 for more information.

Behavioral Health

• Behavioral Health Authorization Form
• Gender Dysphoria Authorization Form
• Intensive In-Home Behavioral Health Treatment (IIBHT) Authorization Form

Customer Service

• High Risk Pregnancy Checklist Form
• Maternity Case Management Flyer
• Oncology Notification Form
• Pregnancy Notification Form

Pharmacy

• Approved Medications, Infusion Auth Form, Medication Auth Form, and other Pharmacy information