List of Common Services and Required Information

Scan Evidence of recent fractures, current medications and if patient had a DEXA within last 2 years.

Medication name, dosage, frequency, clinical indications, and completed health plan prior auth form.

Elective Inpatient Admission
Office notes, history and physical, relevant lab/radiology test results.

Enteral Nutrition
Type of nutritional product, dosage and clinical notes.

Foot Orthotics
Documentation that the member is diabetic.

Non-Participating Provider Requests
Explanation as to why service cannot be provided in-network, if the member has already seen an in-network provider, who is requesting the service (member or provider). Authorization request must be submitted via fax.

PT/OT/Speech therapy extensions
Recent progress notes with goals.

Current O2 saturation level.

Radiology Tests: CT, MRI, PET, SPECT Scans
Recent office notes detailing evidence of conservative treatment to date, whether surgery is planned or not.

Sleep Study
Office notes indicating evidence of suspected sleep apnea.

Second Opinion
State if member has seen an in-network provider.