Prior Authorization Form
Please fill out the Prior Authorization Form (PDF) when requesting a Prior Authorization. Click the button below to download the form. Please check eligibility prior to submitting a pre-authorization request. Requests will not be processed if they are missing any relevant clinical information, the member ID number CPT, ICD-9 Codes or Physician signatures.
Requests for Pre-Authorization should be submitted to:
Notification of Pregnancy Related Care
Prior Authorization is not needed for Pregnancy related care, however notification is required. You may fax the OB Prior Authorization form to the UM department at 202-821-1098. The OB/GYN is responsible for notifying the Trusted/Alere Case Manager at (202) 821-1100 for assistance with support services needed to help the pregnant member during pregnancy. Any high-risk pregnancies due to physical, social or behavioral conditions must be reported to Trusted at the time of the first visit or at the time when the high-risk situation develops during the pregnancy. All high- risk conditions should be reported to the high-risk obstetrical case manager. The case manager can be contacted via phone (202) 821-1100. The high-risk case manager partners with the OB practitioner to provide reinforcement education for the high-risk condition and coordinate services needed. For high-risk situations that require consultation and/or management of a perinatologist, practitioners should contact the high-risk case manager at the number above. She/he will help the member to contact the perinatologist for consultation and/or transition management.Obstetrical Authorizations / Notifications (PDF)