Precertification Requirements and Forms

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Important Changes to Medical Referral Request and Referral and Pre-Authorization Inquiry on ProviderAccess

Effective December 12, 2014, you will only be able to access Medical Referral Request and Referral and Pre-Authorization Inquiry using the Interactive Care Reviewer (ICR) on the Availity Web Site. These functionalities will no longer be available on ProviderAccess. Please begin using the ICR now! Registered Availity users can go to Availity.com and click “Auths and Referrals” located on the left navigation menu. If you do not see “Auths and Referrals”, contact your Availity Primary Access Administrator (PAA). If your organization is not registered for Availity, go to availity.com and click “Get Started”. 
 
Precertification Requirements  
Ancillary Precertification Requirements: Ground Ambulance/Transportation, Non-emergent
Medicare Advantage Precertification Requirements List
Outpatient Diagnostic Imaging Precertification Procedure Codes Sheet - effective 01/01/2013
Radiation Therapy Precertification CPT Codes
SHBP Precertification Procedure Codes Sheet – effective 1/1/2015
SHBP Precertification Requirements List - effective 1/1/2015
Sleep Management Precertification CPT Codes
Standard Precertification Requirements List - effective 8/3/2015
Standard Precertification Procedure Codes Sheet – effective 8/3/2015
 
Precertification Forms  
Cancer Care Quality Program FAQ's
Continuation of Care Coverage Request Form
Medicare Advantage General Precert Form
MPI – Stress Echo Clinical Worksheet
Precertification Form for Procedures and Diagnostics
Pre-Existing condition review for Radiology and Pre-Service Reviews
Primary Care Physicians Referral Form
Request for Transition of Out of Network Care (TOC) – HMO/POS members
Request for Transition of Out of Network Care (TOC) – PPO/ASO Group members
 
Medical-Surgical Clinical Data Submissions Tools  
Medical-Surgical Clinical Data Submissions Tools
 

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