Authorizations

For urgent and emergent pre-authorizations, call the number on the back of the member’s ID card.

Authorization status is available by calling Provider Services via the number on the back of the member’s ID card.

Medical Authorizations

• Medical Authorization Form
• OB Notification Form
• Referral Request for Cleveland Clinic Specialty Service Program (SSP)
• Referral Request for Case Management Services
• OhioHealthy Network Exception Request Form
• Travel and Lodging Benefit Reimbursement Predetermination and Claim Form

Drug Authorizations

All drugs paid under medical coverage, please use the medical authorization form above. For OhioHealth Associates and Unity Plan members, use the Archimedes form below.

• Ohio Healthy Archimedes PA Form for Specialty Drugs
• Medical Benefit Prior Authorization Specialty Drug List
• Pharmacy Benefit Prior Authorization Specialty Drug List

Behavioral Health Authorizations

• Behavioral Health Inpatient Authorization Request
• Behavioral Health Outpatient Authorization Request
• Electroconvulsive Therapy (ECT) Authorization Request
• Behavioral Health Discharge Summary
• Transcranial Magnetic Stimulation (rTMS) Authorization Request Form

Hospital Review Team

• Authorization Request for Inpatient and Observation Services

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Elective admissions/requests should be submitted for pre-authorization as soon as possible or at least 7-10 days prior to scheduling an admission or procedure.

For urgent and emergent pre-authorizations, call the number on the back of the member’s ID card.

Authorization status is available by calling Provider Services via the number on the back of the member’s ID card. Providers are also notified of all authorization decisions in writing (by fax). Elective decisions are typically rendered within 4-5 days from receipt of all requested information. Urgent cases will be completed within 72 hours.

Emergency requests due to life-altering situations will be completed within 24-48 hours.