Prior Authorization Forms for Medicaid and Medicare Advantage Plans
Optima Health Medicaid and Medicare Advantage plans include:
Optima Family Care, Optima Health Community Care, Optima Medicare Value (HMO), Optima Medicare Prime (HMO), Optima Medicare Salute (HMO), and Optima Community Complete (HMO D-SNP)
Prior Authorization Forms
Addiction and Recovery Treatment Services
ARTS DMAS Provider Attestation Form
PDF, 628 KB
PDF, 628 KB
ARTS Peers Registration Request
PDF, 390 KB
PDF, 390 KB
ARTS Peers Service Authorization Guidelines
PDF, 200 KB
PDF, 200 KB
ARTS Service Authorization Review - Extensions
PDF, 871 KB
PDF, 871 KB
ARTS Service Authorization Review - Initial Request
PDF, 856 KB
PDF, 856 KB
ARTS Substance Use Case Management Registration
PDF, 900 KB
PDF, 900 KB
Advanced Imaging
Agency Directed Services
Authorization Request
Continuous Glucose Monitors (CGM) (PREFERRED: Dexcom | FreeStyle Libre 1 | FreeStyle Libre 2 | FreeStyle Libre 3) (Non-Preferred: Eversense | Gaurdian)
PDF, 176 KB
PDF, 176 KB
LTSS Authorization Request Form
PDF, 241 KB
PDF, 241 KB
Part D Redetermination Request (Appeal) Form
PDF, 127 KB
PDF, 127 KB
Pre-Authorization Reconsideration Form
PDF, 157 KB
PDF, 157 KB
Request a standard decision for Medicare Part C (medical items or services)
PDF, 267 KB
PDF, 267 KB
Behavioral Health
Behavioral Health Discharge Summary for Medicare and Medicaid
PDF, 247 KB
PDF, 247 KB
Behavioral Health Inpatient Authorization Request for Medicare and Medicaid
PDF, 239 KB
PDF, 239 KB
Behavioral Health Outpatient Authorization Request for Medicare and Medicaid
PDF, 196 KB
PDF, 196 KB
Electroconvulsive Therapy (ECT) Authorization Request for Medicare and Medicaid
PDF, 273 KB
PDF, 273 KB
Transcranial Magnetic Stimulation (rTMS) Authorization Request Form
PDF, 116 KB
PDF, 116 KB
Consumer Directed Services
Durable Medical Equipment
Home Health
Inpatient and Outpatient Observation
Authorization Request for Currently Hospitalized Members (Inpatient or Observation)
PDF, 55 KB
PDF, 55 KB
Authorization Request for Future Inpatient Services
PDF, 147 KB
PDF, 147 KB
Authorization Request for Future Outpatient Services
PDF, 86 KB
PDF, 86 KB
Authorization Request for Inpatient Skilled Nursing Facility Services
PDF, 113 KB
PDF, 113 KB
Authorization Request for Post-Acute Inpatient Rehabilitation or Long-Term Acute Care
PDF, 91 KB
PDF, 91 KB
Authorization Request Outpatient Physical-Occupational-Speech Therapies
PDF, 122 KB
PDF, 122 KB
Mental Health Services
Addiction And Recovery Treatment Services (ARTS) And Mental Health Services (MHS) Registration Form
Applied Behavior Analysis CONTINUED STAY Service Authorization Request Form
Applied Behavior Analysis INITIAL Service Authorization Request Form
Assertive Community Treatment Continued Stay Service Authorization Request Form
Assertive Community Treatment Initial Service Authorization Request Form
Community Stabilization Continued Stay Service Authorization Request Form - February 14 2023
Community Stabilization Initial Service Authorization Request Form - February 14 2023
Community Stabilization Referral Form
Enhanced Services Individual Service Plan Template
Functional Family Therapy CONTINUED STAY Service Authorization Request Form
Functional Family Therapy Initial Service Authorization Request Form
Intensive In-Home Initial Service Authorization Request Form
Mental Health Intensive Outpatient And Partial Hospitalization Program Continued Stay Service Auth
Mental Health Intensive Outpatient And Partial Hospitalization Program Initial Service Auth Request
Mental Health Skill-Building Initial Service Authorization Request Form
Multisystemic Therapy Continued Stay Service Authorization Request Form
Multisystemic Therapy Initial Service Authorization Request Form
Psychosocial Rehabilitation Initial Service Authorization Request Form
Residential Crisis Stabilization Unit CONTINUED STAY Service Authorization Request Form
Service Authorization Form CMHRS Continued Stay Service Authorization Request Form
Therapeutic Day Treatment Initial Service Authorization Request Form
OBGYN
OB/Prenatal Certification Form
PDF, 390 KB
PDF, 390 KB