Prior Authorization Form Immunomodulators Fax this form to: 1-800-424-3260 A fax cover sheet is not required. (916) 555-1212 metown, CA 98765 Money Bank, Inc. The Prior Authorization Portal makes it easy for you to submit fully electronic prior authorization requests right away. First Steps ($50) Rebate . If you have prior authorization or benefit questions, please call PEHP Customer Service at (801) 366-7555 or toll free at (800) 753-7490. Obtain benefit limits information. INDIVIDUAL PROVIDERS. PEHP Claims Department 560 E 200 S Salt Lake City, Utah 84102-2004. 321 Main Street Hometown, CA For authorization, please answer each question, include patient chart notes to document clinical information, and fax this form back to the PEHP Prior Authorization Department at (801) 245 -7774 or mail to: PEHP Pharmacy services, 560 East 200 South Salt Lake City, UT 84102. » Skilled nursing facilities. The best editor is already at your fingertips giving you various advantageous instruments for submitting a PEHP Health & Benefits Prior Authorization For Anesthesia Services For Dental Procedures Under. Learn more about assistance with Prior Authorization YOU MAY ALSO LIKE: Getting Started Do whatever you want with a PRIOR AUTHORIZATION for GENETIC and - Pehp: fill, sign, print and send online instantly. pehp. , Information for providers and members about which services, surgeries or procedures require authorization before being performed along with how to get that authorization. Need help with your benefits after PEHP regular hours? If you need help with your benefits when PEHP offices are closed, you can find valuable information when you log in to your PEHP account, including benefit summaries, claims, forms, lists of participating providers, access your PEHP ID card, and send us information via the Message Center. Express Scripts Home Delivery Order Form. prior employer. If you have prior Download the Covered Drug List to see the following:. Download pharmacy preauthorization forms. 04. Non-Contracted Provider? Request Preauthorization Do whatever you want with a PRIOR AUTHORIZATION for ANESTHESIA SERVICES for DENTAL : fill, sign, print and send online instantly. 1. 07 Double-check that all information provided is accurate and complete before submitting the prior authorization form. Complete a blank sample electronically to save yourself time and money. If a Prior Authorization is necessary, assistance is available through CoverMyMeds® so that you have more time to focus on what matters most: patient care. For authorization, please complete this form, include patient chart notes to document information and FAX to the PEHP Prior Authorization Department at (801) 366-7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. John Doe 123 Main Street Ph. The forms included below are only for claims to be billed as medical claims direct to PHC. Pehp Prior Authorization Form. PRIOR AUTHORIZATION for UVULOPALATOPHARYNGOPLASTY (UPPP) For authorization, please complete this form, include patient chartnotes to document information and FAX to the PEHP Prior Authorization Department at (801) 366‐7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. You can help us process your completed change form faster by uploading it through the Message Center. 2. Verify and request address changes for both physical and billing addresses. Download medical preauthorization forms. are available on the DHS Pharmacy Services website at Do whatever you want with a PRIOR AUTHORIZATION for SPINAL CORD STIMULATOR (SCS) - Pehp: fill, sign, print and send online instantly. If you have prior authorization or Free access to Retiree Health Insurance Counselors. If you have prior authorization PRIOR AUTHORIZATION for MINIMALLY INVASIVE FUSION OF THE SACROILIAC JOINT (iFuse) For authorization, please complete this form, include patient chartnotes to document information and FAX to the PEHP Prior Authorization Department at (801) 366‐7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. This includes drugs to be administered directly to a member by a medical healthcare provider (hospitals, surgery centers, prescriber offices, and clinics). If you have prior authorization or benefit questions, please call Requesting providers should complete the standardized prior authorization form and all required health plans specific prior authorization request forms (including all pertinent medical documentation) for submission to the appropriate health plan for review. The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. Your doctor can obtain a preauthorization form from the provider section of www. Most doctors know how and when to do this, but it's your responsibility to verify. Our Customer Service Representatives and Provider Specialists answer questions relating to claims, member eligibility, and benefits. Face-to-face meetings available! Call us at (801) 366-7499. For authorization, please complete this form, include patient chartnotes to document information and FAX to the PEHP Prior Authorization Department at (801) 366‐7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. Prior Authorization Formulary Exception Appeal Please complete this form and return via fax: 216. We'll let your office know if the preauthorization request has been approved or denied. 6136 PEHP Customer Service Line: 801-366-7555 or 800-765-7347 (TTY:711) PA Forms for Physicians. This tool is a great option however; EDI claim submission through your practice management software, clearinghouse or UHIN is preferred. Next Steps ($50) Rebate . Pharmacy Preauthorization Forms. Send us your contact information, fax number, and which form (s) you need. O. If you have prior authorization or benefit questions, please call or until I submit a new direct deposit authorization form to Nationwide. Obtain contracted fees via Fee Schedule Lookup. Claim Forms. PRIOR AUTHORIZATION for GENERAL ANESTHESIA for DENTAL SERVICES UNDER MEDICAL For authorization, please complete this form, include patient chart notes to document information and FAX to the PEHP Prior Authorization Department at (801) 366-7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. Otherwise, your benefits could be reduced or denied. You must follow the rules and regulations for prior authorizations that are published in the Texas Medicaid Provider Procedures Manual. When a PA is needed for a prescription, the member will be asked to have the physician or authorized agent of the physician contact our Prior Authorization Department to answer criteria questions to determine coverage. » To change plans, complete the enclosed enrollment change form, listing all covered dependents, and return to PEHP by May 26, 2023. If you are unable to use electronic prior authorization, you can call us at 1 (800) 882-4462 to submit a prior authorization request. Apr 24, 2024 · For imaging, outpatient surgeries and testing, requests for services may be obtained via: Phone: 1-877-647-4848 Fax: 1-866-912-4245; Online: Provider Portal For DME, orthotics, prosthetics, home healthcare, and therapy (physical, occupational, speech), requests for services may be obtained via fax only: 1-866-912-4245. OHA no longer calls providers with prior authorization status. SYNAGIS (pavilizumab ) PRIOR AUTHORIZATION FORM . . , Highmark Benefits Group Inc. 821. If you have prior authorization or Submitting the request: Send the completed prior authorization form, along with supporting documents, to the appropriate department or contact provided by the insurance company. Prior authorization guidelines for . If you have prior PRIOR AUTHORIZATION FOR AUTISM TREATMENT BENEFITS (Dependent Child) For authorization, please submit this form with relevant medical records* to document diagnosis and mail or FAX to PEHP Prior Authorization Department. If you have prior authorization or Since PEHP will be paying claims from two systems during this transition, you will need to submit claims with the correct ID number (as shown on the PEHP ID card). org or call PEHP at 801-366-7555 or 800-765-7347. Ask your provider to go to Prior Authorization Requests to get forms and information on services that may need approval before they prescribe a specific medicine, medical PRIOR AUTHORIZATION for ORTHOGNATHIC SURGERY For authorization, please complete this form, include patient chartnotes to document information and FAX to the PEHP Prior Authorization Department at (801) 366‐7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. Discover your path to wellness with PEHP and win exciting prizes along the way! Whether you’re trying to be more active, improve your eating habits, boost your mental well-being, or get parenting support - you’ll find something to help you achieve your health and wellness goals. Preferred Medications; Non-Preferred Medications; Specialty Medications; Non-Covered Medications Some medical services and medications may need a prior authorization (PA), sometimes called a “pre-authorization,” before care or medication can be covered as a benefit. PROVIDER FIRST LEVEL APPEAL FORM PEHP makes good faith efforts to pay claims quickly and correctly. PEHP Health & Benefits Prior Authorization for Anesthesia Services for Dental Procedures Under Medical 2022-2024 free printable template To open your prior For authorization, please complete this form, include patient chart notes to document information and FAX to the PEHP Prior Authorization Department at (801) 366‐7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. Corrected Claim Request Form Use this form to submit a correction on a rejected claim. 5790 Member Name: Member EHP Insurance ID Number: Member DOB: Requesting Physician’s Name: Office Phone Number: Office Fax Number: For authorization, please complete this form, include patient chart notes to document information and FAX to the PEHP Prior Authorization Department at (801) 366-7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. The following inpatient services require preauthorization by calling PEHP at 801-366-7755 or 800-753-7754: » Inpatient hospital medical admissions at Primary Children’s Medical Center. For your patients without Wegovy™ or Saxenda® coverage: Write a letter to the benefits manager of your patient’s human resources (HR) department to request PRIOR AUTHORIZATION for COCHLEAR IMPLANTS and BONE ANCHORED HEARING AIDS For authorization, please complete this form, include patient chartnotes to document information and FAX to the PEHP Prior Authorization Department at (801) 366‐7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. PRIOR AUTHORIZATION for BONE GROWTH STIMULATOR For authorization, please complete this form, include patient chartnotes to document information and FAX to the PEHP Prior Authorization Department at (801) 366‐7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. Submit Direct Claim Form Electronically. 3334 Portal: www. 442. PRIOR AUTHORIZATION for MENTAL HEALTH SERVICES For authorization, please complete this form, include patient chart notes, including CRISIS EVALUATION, to document information and FAX to the PEHP Prior Authorization Department at (801) 366‐7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. To join a PEHP network, fill out the appropriate form below and send to providersubmissions@pehp. Consideration of coverage of ABA services requires that records include a formal evaluation For authorization, please complete this form, include patient chart notes to document information and FAX to the PEHP Prior Authorization Department at (801) 366-7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. All batch claims must still be submitted through UHIN. The medications on the Covered Drug List provide the best overall value based on quality, safety, effectiveness, and cost. The Prior Authorization Request Form is for use with the following service types: Street Address 201 South Union Street Montgomery, Alabama 36104 Mailing Address P. With US Legal Forms the process of completing official documents is anxiety-free. carecentrixportal. Call PEHP at 801-366-7358 for information on any medication. Obtain deductibles. National Information Center 1 (800) 411-BLUE; Mar 1, 2024 · Prior authorization is a type of approval that is required for many services that providers render for Texas Medicaid. Coordination of Benefits/Direct Claim Form. 0020 Loading. PRIOR AUTHORIZATION for WEARABLE CARDIOVERTER-DEFIBRILLATORS For authorization, please complete this form, include patient chartnotes to document information and FAX to the PEHP Prior Authorization Department at (801) 366‐7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. greater than 6 days requires authorization » Intrathecal pumps » New and unproven technologies » Radiofrequency (RF) neurolysis for back (thoracic, lumbar) or neck (cervical) pain. Find authorization and referral forms. - use Learn how to request prior authorization for your patients' health care services with UMR, a leading third-party administrator of benefits solutions. com or www. On any device & OS. Since PEHP will be paying claims from two systems during this transition, you will need to submit claims with the correct ID number (as shown on the PEHP ID card). For authorization, please complete this form, include patient chart notes to document information and FAX to the PEHP Prior Authorization Department at (801) 366‐7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. a. Claims must be sent on appropriate claim forms: UB-04 or CMS-1500. If you have prior 801-366-7555 or 800-765-7347. Choose Your Path to Wellness . For authorization, please complete this form, include patient chart notes to document information and FAX to the PEHP Prior Authorization Department at (801) 366 -7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. If you have prior At www. You may also call 801-366-7358 for the status of the request. Out of state and out of country coverage Initial Authorization . Try Now! *After five unsuccessful log in attempts, your account will be locked and you will need to contact Customer Services and Provider Specialists: 801-366-7555 or 800-765-7347. 2022 PEHP Anesthesia Services / Non-Standard Place of Service Page 1 of 2 For authorization, please complete this form, include patient chart notes to document information and FAX to the PEHP Prior Authorization Department at (801) 366-7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. 517. If PRIOR AUTHORIZATION for GENERAL ANESTHESIA for DENTAL SERVICES UNDER MEDICAL For authorization, please complete this form, include patient chart notes to document information and FAX to the PEHP Prior Authorization Department at (801) 366-7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. org you will see which drugs require preauthorization. Box 302150 Montgomery, Alabama 36130-2150. Handwritten claims will not be accepted. How to Check Prior Authorization Status. Prior authorization checklist For DUPIXENT® (dupilumab) in patients 6 months and older with uncontrolled moderate-to-severe atopic dermatitis (AD) A patient’s health plan is likely to require a prior authorization (PA) before it approves DUPIXENT for appropriate patients. Fax: (206) 652-707 Prior Authorization Request Form For expedited processing for both Apple Health, Medicare Advantage Plans and Cascade Select please submit Prior Authorization requests via The following inpatient services require preauthorization by calling PEHP at 801-366-7755 or 800-753-7754: » Inpatient hospital medical admissions at Primary Children’s Medical Center. If you have prior Standard Authorization: Most services if requested by or with a written order from a PCP or Plan NP are “auto-authorized” within 8 hours or less. » All inpatient mental health and substance abuse admissions. If you have prior authorization Sleep Study Prior Authorization Request Form Phone: 855. CMS allows 14 days for standard authorizations. The transition to the new system will be done in phases by employer renewal dates. The most recent clinical Before you get started, in addition to your insurance card, you will need the following information. Other rebates you may be eligible to earn: Choose Your Path to Wellness . com This form must be completed in its entirety for all faxed sleep diagnostic prior authorization requests. If you have prior authorization Public Service Health Care Plan - Drug Prior Authorization Send all forms and applicaple patient notes to document clinical information. If you have prior authorization For authorization, please complete this form, include patient chartnotes to document information and FAX to the PEHP Prior Authorization Department at (801) 366 ‐ 7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. » Transcranial Magnetic Stimulation » Wound care products » Wound vac MEDICAL EQUIPMENT (DME) LABORATORY 401(a)/403(b)/401(k) Plan Distribution Request Form (PDF) Use this form(s) to: Select your payout options when you end your employment or retire; Request a payout; Stop current payouts; Change a current payout; Restart a payout; Defer payout until Required Minimum Distribution (RMD) is required at age 70½; PEHP Claim Reimbursement Form (PDF Submit the prior authorization request: Submit the completed prior authorization form and any supporting documents according to the provider's or insurance company's specified method. Please check Member’s Plan UPHP Medicaid PRIOR AUTHORIZATION for NEUROLYSIS and PAIN MANAGEMENT PROCEDURES . com Updated 06/19/18 UPHP PRIOR AUTHORIZATION (PA) REQUEST FORM FAX TO 906-225-9269 A. If you have preauthorization questions, call PEHP at 801-366-7555. Synagis . If you have prior Submit Electronic Prior Authorization Requests Free Secure Easy. If a form for the specific medication cannot be found, please use the Global Prior Authorization Form. Contact Us. This may include mailing, faxing, or submitting electronically through their online portal. Please refer to the specialty medication section of the Preferred Drug List. DME Authorization Request Form Use this form to easily request authorization for DME. For contact information for specialty vendors other than Accredo, call PEHP at 801-366-7555 or 800-765-7347. To find out the status of a prior authorization request submitted to OHA: PRIOR AUTHORIZATION for NUTRITIONAL SUPPORT For authorization, please complete this form, include patient chartnotes to document information and FAX to the PEHP Pharmacy Department at (801) 245‐7774 or mail to: 560 East 200 South Salt Lake City, UT 84102. If you have prior authorization or For authorization, please complete this form, include patient chart notes to document information and FAX to the PEHP Prior Authorization Department at (801) 366-7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. WWW. Prior Authorization assistance. uphp. 877. Codes (include all applicable): CPT (Current Procedural Terminology) %PDF-1. If you have prior Molina Healthcare, Inc. 5 %âãÏÓ 10 0 obj > endobj xref 10 61 0000000016 00000 n 0000001851 00000 n 0000001960 00000 n 0000002454 00000 n 0000002598 00000 n 0000002741 00000 n 0000003015 00000 n 0000003607 00000 n 0000003881 00000 n 0000004385 00000 n 0000004933 00000 n 0000004968 00000 n 0000005469 00000 n 0000005580 00000 n 0000005605 00000 n 0000006172 00000 n 0000006839 00000 n 0000007535 00000 n For authorization, please complete this form, include patient chart notes to document information and FAX to the PEHP Prior Authorization Department at (801) 366-7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. FAQ > Prior Authorization assistance. If you have prior authorization or benefit questions, please call PEHP Pharmacy Department at (801) 366-7551 or toll free at (888) 366-7551. If you have prior authorization or benefit questions, please Partnership HealthPlan Prior Authorization Forms, for MEDICAL Benefit Claims:. sleepsms. If you have prior authorization or benefit questions, please call For authorization, please complete this form, include patient chartnotes to document information and FAX to the PEHP Prior Authorization Department at (801) 366‐7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. Securely download your document with other editable templates, any time, with PDFfiller. pharmacy and overseas claim forms. No paper. If you have prior a uthorization questions, you may contact the PEHP For authorization, complete this form, include patient chart notes to document information, and FAX to the PEHP Pharmacy Department at (801) 245-7774 or mail to: 560 East 200 South Salt Lake City, UT 84102. Follow the specified submission instructions carefully to ensure your request is received and processed promptly. Skip to main content Medical: 800. If you have prior authorization or benefit questions, please The requested drug will be covered with prior authorization when the following criteria are met: • The patient has a diagnosis of type 2 diabetes mellitus AND • The patient has NOT been receiving a stable maintenance dose of a GLP-1 (glucagon-like peptide 1) Agonist for Oct 1, 2023 · Procedures and services requiring prior authorization – Please refer to these guidelines to find which procedures will require us to issue an authorization for patients with a Medicare plan (also available in Excel) Authorization Form - use this form for submitting a medical authorization request ; Behavioral health authorization form. Wellness Rebate Forms. For authorization, please complete this form, include patient chartnotes to document information and FAX to the PEHP Prior Authorization Department at (801) 366 ‐ 7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. Web forms electronic trading partner agreement (etpa) form must be executed by the provider before they are allowed access to. If you have prior authorization or benefit questions, please Obtaining medications through Accredo or PEHP's approved home health providers allows PEHP members to receive the lowest cost maximum benefit available to them. » All inpatient hospital rehabilitation admissions. Individual Medical Provider Application and Agreement (pdf) Individual Dental Provider Application and Agreement (pdf) 1 results found for search term : prior authorization forms. org or may call PEHP at 801-366-7555 or 800-765-7347. For the latest list, go to www. *The preauthorization list may be subject to change. Review PEHP’s claim auditing rules and clinical rationale via Clear Claim Connection. Pharmacy Forms. com 853 West Washington Street * Marquette, Michigan 49855 * 906-225-7500 * (FAX) 906-225-9269 * 1-800-835-2556 * www. Customer Services and Provider Specialists. Choose a Prior Authorization Portal to Get Started EviCore ® by Evernorth PRIOR AUTHORIZATION for AIRWAY CLEARANCE DEVICES For authorization, please complete this form, include patient chartnotes to document information and FAX to the PEHP Prior Authorization Department at (801) 366‐7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. Required Information for Claims Submission. Try Now! PEHP is replacing its claims payment and administration system to better serve you and our members. If you have prior authorization or benefit questions, please PRIOR AUTHORIZATION for BREAST RECONSTRUCTION For authorization, please complete this form, include patient chartnotes to document information and FAX to the PEHP Prior Authorization Department at (801) 366‐7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc. Pharmacy Specialty, Infusion Referral, and Mail-Order Forms After receiving a pre-populated prior authorization from CoverMyMeds®, please complete and submit it to help your patient with obtaining access to Wegovy™ after the first 6 fills. List the Prior Authorization Number for the existing request on the EDMS Coversheet; otherwise, the request will be processed as a new request, delaying review. Medicaid Medical Pharmacy (J codes) are authorized by UPHP please go to see forms on www. If a service requires prior authorization but the request for prior authorization is not submitted or is denied, the claim will not be paid. Until the transition is complete, you may need to login to your existing and new provider account to verify member benefits eligibility, submit claims, see claim Out-of-Network Authorization Request Form. The PEHP online claims tool only allows claims to be submitted individually and does not provide batch claim functionality. Blue Shield Medicare. No EHR needed, no technology integration, and no cost to you—just quick and easy electronic prior authorizations Initiate prior authorization requests; For prior authorization status inquiries, call Magellan Medicaid Administration Pharmacy Support Center at 800-922-3987; Prior authorization fax Fax: 800-327-5541 Magellan Medicaid Administration Pharmacy Support Center Provider line: 800-922-3987 (available 24 hours/day, 365 days/year) Participant line PEHP Customer Service Line: 801-366-7555 or 800-765-7347 (TTY:711) . © 2017–2021, Magellan Health, Inc. Appeal Request Form Use this form to submit a request to appeal a claim. This information can be obtained by contacting your prescribing physician. Electronic Trading Partner Agreement (ETPA) form must be executed by the provider before they are allowed access to the PEHP Provider secure website which provides member eligibility, claims status, Clear Claim Connection (PEHP claim edit tool), Pharmacy Prior-Authorization forms, and other proprietary information. The days of terrifying complicated legal and tax forms are over. – Prior Authorization Request Form Author: CQF Subject: Accessible PDF Keywords: 508 Created Date: 5/6/2024 10:51:21 AM Attach all the supporting documentation to the prior authorization form, ensuring that all pages are clearly labeled with the patient's name and medical record number. PRIOR AUTHORIZATION for ANESTHESIA SERVICES / NON-STANDARD PLACE OF SERVICE For authorization, please complete this form, include patient chartnotes to document information and FAX to the PEHP Prior Authorization Department at (801) 366‐7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. of . If you have prior authorization or the list at any time. 01. The Covered Drug List is a listing of prescription medications chosen by PEHP to be available at a lower copayment. Xolair will be approved based on one of the following criteria: (1) Both of the following: (a) Patient has been established on therapy with Xolair for chronic urticaria under an active UnitedHealthcare medical benefit prior authorization -AND- (b) Documentation of positive clinical response to Xolair therapy -OR- Referral/Authorization Request Use this form to submit a request for a referral or authorization. If you have prior To get preauthorization, your doctor must call PEHP (801-366-7555). Rx DirectPay Program Form . PEHP. Simply snap a photo or scan your completed form, PRIOR AUTHORIZATION for HEARING AIDS . 2021 PEHP Hearing Aids Page . 243. PRIOR AUTHORIZATION for RADIATION THERAPY For authorization, please complete this form, include patient chartnotes to document information and FAX to the PEHP Prior Authorization Department at (801) 366‐7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. To verify your patient’s current PEHP ID number, please use the Member ID Lookup Tool available in the Classic Account -->Choose Provider-->Member ID Lookup Tool. to represent you and have not already submitted an Lude patient chart notes to document information and FAX to the PEHP Prior Authorization Department at (801) 366-7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. In the event this direct deposit authorization form is incomplete or contains incorrect information, I understand a check will be issued to my address of record. ORG 2024-2025 PEHP Medical Master Policy 7-9-24 Medical Master Policy 2024-2025 Do whatever you want with a PRIOR AUTHORIZATION for ANESTHESIA SERVICES: fill, sign, print and send online instantly. org. If you have prior PEHP has an open provider panel and welcomes new applications from individual providers and groups. PRIOR AUTHORIZATION for MECHANICAL STRETCHING DEVICES for CONTRACTURE and JOINT STIFFNESS For authorization, please complete this form, include patient chartnotes to document information and FAX to the PEHP Prior Authorization Department at (801) 366‐7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. If you have prior authorization or benefit questions, please PEHP Health & Benefits Prior Authorization For Anesthesia Services For. 2022 PEHP Autism Services Page 1 of 1 *Please fax completed form and medical records to 801-366-7449. 3326 Fax: 855. Complete a blank sample electronically to save yourself time and Forms are available at myPEHP for Providers. The Form effective 7/1/2022 Office of Medical Assistance Programs Fee-for-Service, Pharmacy Division Phone 1-800-537-8862 Fax 1-866-327-0191 . Fax the form back to the PEHP Case Management Department at 801-328-7449 or mail to: PEHP Case Management, 560 East 200 South Salt Lake City, UT 84102. Non-formulary exception and quantity limit exception (PDF, 129 KB) Prior authorization/coverage determination form (PDF, 136 KB) Prior authorization generic fax form (PDF, 201 KB) Prior authorization urgent expedited fax form (PDF, 126 KB) Tier exception (PDF, 109 KB) Obtain the appropriate PA form after initiating your patient through one of the following: DUPIXENT MyWay ® • CoverMyMeds • Insurance provider • Specialty pharmacy PRIOR AUTHORIZATION for WOUND CARE For authorization, please complete this form, include patient chartnotes to document information and FAX to the PEHP Prior Authorization Department at (801) 366‐7449 or mail to: 560 East 200 South Salt Lake City, UT 84102. 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