Prior Authorization Denials

Please use the form below if you would like to submit additional clinical information that justifies the medical necessity of a denied case. Requests not related to the submission of additional clinical information for a denied case will not be processed if submitted via the form below. Please note that only .PDF and .TIF file types can be supported.

Request Form

Please enter Case Number/Authorization Number
Please enter valid Email
Please enter Patient ID
Please enter Patient last name
Please enter Patient DOB
Please enter Contact Phone
Please enter Member's health plan
Please select request type
Please enter Reason for Request

Expedited cannot be completed online at this time. For expedited submission of information to a Denied case, please call 800-792-8744, option 4.