Provider Authorizations

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 - Fully Funded
  • Medical Authorization Form - Self Funded
  • Medical Authorization Form - Level Funded
  • 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 Drug Provider fax form below. For Prescription Drug Forms refer to the Pharmacy page

 

  • OhioHealthy Archimedes PA Form for Specialty

Hospital Review Team 

Elective admissions/requests should be submitted for pre-authorization as soon as possible or within 10 calendar 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 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.