PEBTF referral

• PEBTF referral form

Behavioral health

• Behavioral health professional services questionnaire
• Behavioral health facility services questionnaire
• Behavioral health outpatient prior authorization request form
• Behavioral health services review form
• Behavioral health ABA request form - As of Jan. 1, 2023 Applied Behavioral Analysis no longer requires prior authorization when the provider is in-network, the member’s plan covers autism and there is a diagnosis of Autism Spectrum Disorder. If you're unsure if a prior authorization is required or if the member’s plan has coverage for Autism, call the our care connector team at 888-839-7972.
• Behavioral health ECT request form
• Behavioral health psychological testing request form
• Behavioral health TMS request form
• Behavioral health discharge form

DME

• DME ordering through Tomorrow Health - As of Jan. 1, 2021, all DME orders for your GHP patients should be placed through Tomorrow Health.
• DME Precertification Additional Code Form
• DME Precertification Form
• DME Authorization Change Form
• DME Re-Certification Form

Home health

• As of Jan. 16, 2023, you can submit prior authorization requests for home health through Cohere Health. Cohere’s online portal is an easy way to get authorization requests reviewed and approved quickly so your patients can get the care they need. Register with Cohere today!

• Home Health Services Request Form

Inpatient

• Inpatient Admission Review Form
• Inpatient Planned Procedure Precertification Form
• Inpatient Rehabilitation Precertification Form
• Inpatient Update Review Form

Medical Benefit Outpatient Drug

• Medical Drug Prior Authorization List (GHP Family-Medicaid)
• Medical Benefit Outpatient Drug Authorization Form
• Medical Drug Prior Authorization List (Commercial/Marketplace/Medicare/CHIP)

Outpatient rehabilitation

• As of Jan. 16, 2023, you can submit prior authorization requests for outpatient therapy services through Cohere Health. Cohere’s online portal is an easy way to get authorization requests reviewed and approved quickly so your patients can get the care they need. Register with Cohere today!

• Outpatient Rehabilitation Therapy Services Request Form

SNF

• SNF Concurrent Review Form
• SNF Discharge Planning Notification Form
• SNF Precertification Form

Additional forms and resources

• Newborn Information Form
• NOMNC-Sample Instructions
• Non-Emergent Transport Form
• Open Negotiation Period Form
• Organizational Determination Form
• Outpatient Prior Authorization Form
• Prior Authorization List