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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

View requirements for Local Plan and BlueCard Out-of-Area members.

Search our online provider directory when you need a doctor, hospital, or other health care provider.

Medical-Surgical Clinical Data Submissions Tools

PW_E175940
A Pre-certification or Predetermination Tool is used by the provider to submit clinical information for an authorization request (precert or predetermination). If a provider uses this tool, chart records and letters of medical necessity will not be needed unless the tool is selected for auditing.  

Please complete the necessary information on the first page of the Pre-certification or Predetermination Tool you are using and mark the appropriate lines according to the member’s condition/history. The physician or physician representative needs to sign the bottom of the Provider Tool stating the information is accurate. The tool should then be faxed or mailed to the Utilization Management department for review. The following tools are formatted for submission via fax or mail. If you would like to use a tool and submit it using eReview, please contact the Utilization Management Department.

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