Members & Providers

Alaska

• Physician Certification Expedited External Review Request FormOpens as PDF
• Physician Certification Standard Experimental and Investigational External Review Request FormOpens as PDF
• Physician Certification Standard External Review Request Form Opens as PDF
• External Review Request FormOpens as PDF
• Physician Certification Expedited Experimental and Investigational External Review Request FormOpens as PDF

Arkansas

• Precertification Request Form for Prescription Medications Opens as PDF
• Arkansas UM statistics Opens as PDF
• External Review Request Form Opens as PDF
• Physician Experimental & Investigational External Review Form Opens as PDF
• Physician Expedited External Review Request Form Opens as PDF
• Guidelines and Review Criteria Opens as PDF

Arizona

• Prior Auth Request Form – Health Care Services Opens as PDF
• Prior Auth Request Form – Medications and DME Opens as PDF
• Appeal Request Form Opens as PDF
• External Review Request Form Opens as PDF
• Provider Cert for Expedited Reviews Opens as PDF
• Appeal information for Boon Group members: https://www.aetna.com/health-care-professionals/disputes-appeals/disputes-appeals-overview.html

California

• Prescription Drug Prior Authorization or Step Therapy Exception Request Form Opens as PDF
• California Independent Medical Review Application Opens as PDF
• Experimental and Investigational Physician Certification Form Opens as PDF

Colorado

• Medication Prior Authorization Request Form – CO Opens as PDF

Connecticut

• Guidelines and Review Criteria Opens as PDF

Florida

• Prior Authorization Form Opens as PDF

Georgia

• Georgia UM Pre-Cert Statistics 2023 Opens as PDF

Illinois

• Precertification Request Form for Prescription Medications Opens as PDF
• External Review Request Form – IL Opens as PDF
• Physician Certification for E&I External Review – IL Opens as PDF
• Physician Certification for Expedited External Review – IL Opens as PDF
• Illinois UM Pre-Cert Statistics 2020 Opens as PDF
• Illinois UM Pre-Cert Statistics 2021 Opens as PDF
• Illinois UM Pre-Cert Statistics 2022 Opens as PDF
• Illinois UM Pre-Cert Statistics 2023 Opens as PDF
• Guidelines and Review Criteria Opens as PDF

Indiana

• Indiana – Prior Authorization Form Opens as PDF
• 2023 Prior Authorization Statistics

Kentucky

Nippon member portal (Nippon Life Benefits groups only)

• Guidelines and Review Criteria Opens as PDF

Massachusetts

• Behavioral Health LOC Request Form Opens as PDF
• Cardiac Imaging Prior Auth Form Opens as PDF
• CT, CTA, MRI, MRA Prior Auth Form Opens as PDF
• Hep C Medication Prior Auth Form Opens as PDF
• Non-OB Ultrasound Prior Auth Form Opens as PDF
• PET – PET CT Prior Auth Form Opens as PDF
• Psych and Neuropsych Assessment Supplemental Form Opens as PDF
• Repetitive Transcranial Magnetic Stimulation Request Form Opens as PDF
• Standard Medication Prior Auth Form Opens as PDF
• Synagis Prior Auth Form Opens as PDF
• External Review Request Form Opens as PDF

If you need assistance or have questions, the Massachusetts Health Policy Commission may be able to assist you by contacting:

Massachusetts Health Policy Commission
Office of Patient Protection
50 Milk Street
Boston MA 02109

800-436-7757 (phone)
1-617-624-5046 (fax)

http://www.mass.gov/anf/budget-taxes-and-procurement/oversight-agencies/health-policy-commission/patient-protection/

Maryland

• Uniform Treatment Plan Form—Mental Health and Substance Use Opens as PDF

Michigan

• Request for External Review Form – MI Opens as PDF
• Physician Certification for E&I External Review – MI Opens as PDF
• Guidelines and Review Criteria Opens as PDF

Mississippi

• External Review Application Opens as PDF

New Hampshire

• Medication Prior Authorization Form – NH Opens as PDF

New Jersey

• Provider Complaint Form Opens as PDF
• External Appeal Request Forms Opens as PDF

New Mexico

• Prior Auth Request Form Opens as PDF

New York

• External Appeal Instructions Opens as PDF
• External Appeal Application Opens as PDF
• Behavioral Health Admission Notification Form Opens as PDF
• Form to designate a representative Opens as PDF
• Guidelines and Review Criteria Opens as PDF

Ohio

• External Review Request Forms Opens as PDF

Oklahoma

• Precertification Request Form for Prescription Medications Opens as PDF

Oregon

• Uniform Prior Auth. Prescription Request Form Opens as PDF

Pennsylvania

• Guidelines and Review Criteria Opens as PDF

South Carolina

• External Review Information and Forms Opens as PDF

Tennessee

• Utilization Management Program (Nippon Life Benefits groups only) Opens as PDF
• Grievance Program (Nippon Life Benefits groups only) Opens as PDF
• External Review (Nippon Life Benefits groups only) Opens as PDF

Texas

• Health Services Prior Authorization Form Opens as PDF
• TX Independent Review Request Form—English Opens as PDF
• TX Independent Review Request Form—Spanish Opens as PDF
• Medication or DME Uniform Prior Authorization Form Opens as PDF

Virginia

• Virginia External Review FormOpens as PDF
• Virginia Physician Cert for Expedited ER FormOpens as PDF
• Virginia Physician Cert for E&I FormOpens as PDF
• Virginia Appointment of Auth Representative FormOpens as PDF

Washington

• Guidelines and Review CriteriaOpens as PDF
• Confidentiality Request FormOpens as PDF