If an alternative medication below is appropriate click select. Otherwise proceed to the next section.
To proceed with the current Authorization Request click the "NEXT" button below:
See below to upload documentation and add supporting notes related to the request.
Disclaimer:"Eligibility must be validated within 5 days of the actual date of service. We reserve the right to revoke authorizations based on cancellation of the member's eligibility. Final determination of benefits will be made after review of the submitted claim for limitations or exclusions. In accordance with the facility contract, prior authorization for inpatient facility services must be obtained to avoid potential reduction of payment for services rendered."
The request needs further clinical review. The plan will notify you of the outcome within required time frames
Please have member contact benefits manager if they believe this may be a mistake. Contact Home Town Health at 1-800-555-1234 or benefits@hometownhealth.com
If you believe you may have made a mistake please CLICK HERE to search again.
If this was not a mistake you can send the member a notification letter: Send
"Member not found."
1
"You have decided to prescribe an alternative medication. No prior authorization is required to prescribe the medication for your patient."
"You have selected an Expedited review but have not checked the Expedited Review statement. Acknowledge this statement or select the Authorization Urgency as Standard."
"You have selected Expediated Appeal. Please acknoledge it by checking the `Expedited Appeal` checkbox."
"Please enter at least one Diagnosis."
"Please select a Request Reason."
"Please enter Contact Name/Number."
"Please enter at least one Medication."
"Please enter Fax Number."
"Please enter SIG."
"Provider Fax: Invalid value."
"Provider Phone: Invalid value."
Cannot create authorization for this member.
"Please fill all the required items."