Medical Management / Behavioral Health

• HEP C:
  • 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.

**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
• Ancillary Services:
  • PT/OT/Speech Authorization Form
  • DME Authorization Form
• Behavioral Health Authorization Form
• CDRC Authorization Form
• Gender Dysphoria Authorization Form
• Intensive In-Home Behavioral Health Treatment (IIBHT) Authorization Form
• High Risk Pregnancy Checklist Form
• Home Health Authorization Form
• Hospice Service Authorization Form
• Hospital Length Of Stay Authorization Form
• Infusion Service Authorization Form
• Maternity Case Management Flyer
• Oncology Notification Form
• Physician Authorization Referral Form
• Pregnancy Notification Form
• Rick’s Medical Supply DME Prescription Form
• Skilled Nursing Facility Authorization Form