Utilization Management

Forms & Resources

Authorization Change Request Form - All services EXCEPT diagnostic/advanced imaging, radiation oncology, and genetic testing

If you need to change a facility name, dates of service or number of units/days on an existing authorization, utilize the portal on Availity.com or fax the Authorization Change Request Form to 1-888-319-6479. This form is NOT intended to add codes to an existing authorization. For approval of additional services, please submit a new authorization request.

IFP Provider Services Phone Number: 866-239-7191

Individual and Family Plans (IFP) or Small Group

Authorization Resources

To submit authorizations for all services except diagnostic/advanced imaging, radiation oncology, and genetic testing, please either:

Submit electronically via Availity.com (preferred method), OR
Use the below fax forms.

To submit authorizations for diagnostic/advanced imaging, radiation oncology, and genetic testing, please visit AIM’s ProviderPortal, or call AIM at (833) 305-1802, Monday-Friday 7am-7pm CT, excluding holidays. If authorization changes are needed, please use AIM’s ProviderPortal or call their call center. Note: Dates of Service cannot be changed or extended in an authorization.

2022 AIM Resources – Radiology, Radiation Oncology, Genetic Testing

Standard Prior Authorization Form – AZ

Forms & Resources

Authorization Change Request Form - All services EXCEPT diagnostic/advanced imaging, radiation oncology, and genetic testing

If you need to change a facility name, dates of service or number of units/days on an existing authorization, utilize the portal on Availity.com or fax the Authorization Change Request Form to 1-888-319-6479. This form is NOT intended to add codes to an existing authorization. For approval of additional services, please submit a new authorization request.

IFP Provider Services Phone Number: 866-239-7191

Small Group Provider Services Phone Number: 855-521-9364

Medicare Advantage

Authorization Resources

MA Authorization Fax Form – All services EXCEPT Acupuncture and Chiropractic.

Forms

Submit an authorization to Bright HealthCare for all MA services (except for Acupuncture and Chiropractic services) by submitting electronically via Availity.com or faxing the below form to 1-888-337-2174.

MA Patient Referral Form – All services EXCEPT Acupuncture and Chiropractic.

Authorization Change Request Form - All services EXCEPT Acupuncture and Chiropractic.

If you need to change a facility name, dates of service or number of units/days on an existing authorization, call 844-926-4522 or fax the Authorization Change Request Form to 1-888-337-2174. This form is NOT intended to add codes to an existing authorization. For approval of additional services, please submit a new authorization request.

MA Fax Number: 1-888-337-2174

MA Provider Services Phone Number: 1-844-926-4522

Submit an authorization to American Specialty Health (ASH) for Acupuncture and Chiropractic services by going to ASH’s website and using their online portal or fax forms.

For questions about an authorization or to change an authorization, contact ASH Provider Services at (800) 972-4226.

American Specialty Health Contact Information:

Provider Services phone number: (800) 972-4226 | Fax Number: (877) 304-2746

Individual and Family Plans (IFP)

Authorization Resources

Submit an authorization to American Specialty Health (ASH) for Acupuncture and Chiropractic services by going to ASH’s website and using their online portal or fax forms.

For questions about an authorization or to change an authorization, contact ASH Provider Services at (800) 972-4226.

American Specialty Health Contact Information:

Provider Services phone number: (800) 972-4226 | Fax Number: (877) 304-2746

Hill Physician Medical Group – Contra Costa County

Hill Physicians Medical Group Customer Service Phone: 1-800-445-5747
To request access to the provider portal, complete this form
Hill Physician Medical Group Website
Hill Physician Medical Group
Authorization Request Fax Form (Fax numbers are provided at the top of the form)

John Muir Physician Network – Contra Costa County

Phone (925) 952-2887
Fax: (925) 952-2865
John Muir Health Website

Submit an authorization to Beacon Health for behavioral health services by visiting their website below:

Beacon Health Options of California (beaconhealthoptionsca.com)
Beacon phone number for members and providers: 866-402-7483

To submit an authorization for out-of network care or transplant services to Bright HealthCare, fax the form below to 1-877-438-6832.

Forms

IFP Provider Services Phone Number: 844-926-4525

Medicare Advantage

Authorization Resources

MA Provider Services Phone Number: 844-926-4522

Individual and Family Plans (IFP) or Small Group

Authorization Resources

To submit authorizations for all services except diagnostic/advanced imaging, radiation oncology, and genetic testing, please either:

Submit electronically via Availity.com (preferred method), OR
Use the below fax forms.

To submit authorizations for diagnostic/advanced imaging, radiation oncology, and genetic testing, please visit AIM’s ProviderPortal, or call AIM at (833) 305-1802, Monday-Friday 7am-7pm CT, excluding holidays. If authorization changes are needed, please use AIM’s ProviderPortal or call their call center. Note: Dates of Service cannot be changed or extended in an authorization.

2022 AIM Resources – Radiology, Radiation Oncology, Genetic Testing

Forms & Resources

Authorization Change Request Form - All services EXCEPT diagnostic/advanced imaging, radiation oncology, and genetic testing

If you need to change a facility name, dates of service or number of units/days on an existing authorization, utilize the portal on Availity.com or fax the Authorization Change Request Form to 1-888-319-6479. This form is NOT intended to add codes to an existing authorization. For approval of additional services, please submit a new authorization request.

IFP Provider Services Phone Number: 866-239-7191

Small Group Provider Services Phone Number: 855-521-9364

Medicare Advantage

Authorization Resources

MA Authorization Fax Form – All services EXCEPT Acupuncture and Chiropractic.

Forms

Submit an authorization to Bright HealthCare for all MA services (except for Acupuncture and Chiropractic services) by submitting electronically via Availity.com or faxing the below form to 1-888-337-2174.

MA Patient Referral Form – All services EXCEPT Acupuncture and Chiropractic.

Authorization Change Request Form - All services EXCEPT Acupuncture and Chiropractic.

If you need to change a facility name, dates of service or number of units/days on an existing authorization, call 844-926-4522 or fax the Authorization Change Request Form to 1-888-337-2174. This form is NOT intended to add codes to an existing authorization. For approval of additional services, please submit a new authorization request.

MA Fax Number: 1-888-337-2174

MA Provider Services Phone Number: 1-844-926-4522

Submit an authorization to American Specialty Health (ASH) for Acupuncture and Chiropractic services by going to ASH’s website and using their online portal or fax forms.

For questions about an authorization or to change an authorization, contact ASH Provider Services at (800) 972-4226.

American Specialty Health Contact Information:

Provider Services phone number: (800) 972-4226 | Fax Number: (877) 304-2746

Bright HealthCare Data Regarding Approvals and Denials of Prior Authorization Requests

Colorado

Per prior authorization bill HB19-1211 or C.R.S. § 10-16-112.5, the state of Colorado requires carriers and organizations to publish prior authorization data.

Individual and Family Plans (IFP)

Authorization Resources

To submit authorizations for all services except diagnostic/advanced imaging, radiation oncology, and genetic testing, please either:

Submit electronically via Availity.com (preferred method), OR
Use the below fax forms.

To submit authorizations for diagnostic/advanced imaging, radiation oncology, and genetic testing, please visit AIM’s ProviderPortal, or call AIM at (833) 305-1802, Monday-Friday 7am-7pm CT, excluding holidays. If authorization changes are needed, please use AIM’s ProviderPortal or call their call center. Note: Dates of Service cannot be changed or extended in an authorization.

2022 AIM Resources – Radiology, Radiation Oncology, Genetic Testing

Forms & Resources

Authorization Change Request Form - All services EXCEPT diagnostic/advanced imaging, radiation oncology, and genetic testing

If you need to change a facility name, dates of service or number of units/days on an existing authorization, utilize the portal on Availity.com or fax the Authorization Change Request Form to 1-888-319-6479. This form is NOT intended to add codes to an existing authorization. For approval of additional services, please submit a new authorization request.

IFP Provider Services Phone Number: 866-239-7191

Medicare Advantage

Authorization Resources

MA Authorization Fax Form – All services EXCEPT Acupuncture, Chiropractic and Therapeutic Massage.

Forms

Submit an authorization to Bright HealthCare for all MA services (except for Acupuncture and Chiropractic services) by submitting electronically via Availity.com or faxing the below form to 1-888-337-2174.

Authorization Change Request Form - All services EXCEPT Acupuncture and Chiropractic.

If you need to change a facility name, dates of service or number of units/days on an existing authorization, call 844-926-4522 or fax the Authorization Change Request Form to 1-888-337-2174. This form is NOT intended to add codes to an existing authorization. For approval of additional services, please submit a new authorization request.

MA Fax Number: 1-888-337-2174

MA Provider Services Phone Number: 1-844-926-4522

Submit an authorization to American Specialty Health (ASH) for Acupuncture and Chiropractic services by going to ASH’s website and using their online portal or fax forms.

For questions about an authorization or to change an authorization, contact ASH Provider Services at (800) 972-4226.

American Specialty Health Contact Information:

Provider Services phone number: (800) 972-4226 | Fax Number: (877) 304-2746

Individual and Family Plans (IFP)

Authorization Resources

To submit an authorization for all services except medical specialty pharmacy services, please either:

Submit electronically via Availity.com (preferred method), OR
Fax the below Authorization Fax Form to 1-877-438-6832.

Submit authorization requests for medical specialty pharmacy these drugs to Magellan Rx in the following ways:

For non-urgent requests, please contact Magellan Rx through the provider portal or by phone:

Provider portal: If the provider contracts directly with Bright HealthCare, log on to MRxGateway.com and click Request Prior Authorizations
Phone: Call Magellan Rx at 800-424-2804* weekdays between 8:00 a.m. and 6:00 p.m. local time.

For urgent requests**, please call Magellan Rx at 800-424-2804*. Lines are open 24 hours a day, 7 days a week.

*Phone number goes live Oct. 1, 2022.

**Urgent requests mean that following the standard timeframe could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function.

Forms & Resources

If you need to change a facility name, dates of service or number of units/days on an existing authorization, call 844-926-4525 or fax the Authorization Change Request Form to 1-877-438-6832. This form is NOT intended to add codes to an existing authorization. For approval of additional services, please submit a new authorization request.

IFP Provider Services Phone Number: 844-926-4525

Individual and Family Plans (IFP)

Authorization Resources

To submit authorizations for all services except diagnostic/advanced imaging, radiation oncology, and genetic testing, please either:

Submit electronically via Availity.com (preferred method), OR
Use the below fax forms.

To submit authorizations for diagnostic/advanced imaging, radiation oncology, and genetic testing, please visit AIM’s ProviderPortal, or call AIM at (833) 305-1802, Monday-Friday 7am-7pm CT, excluding holidays. If authorization changes are needed, please use AIM’s ProviderPortal or call their call center. Note: Dates of Service cannot be changed or extended in an authorization.

2022 AIM Resources – Radiology, Radiation Oncology, Genetic Testing

Forms & Resources

Authorization Change Request Form - All services EXCEPT diagnostic/advanced imaging, radiation oncology, and genetic testing

Biomarker Testing Coverage

If you need to change a facility name, dates of service or number of units/days on an existing authorization, utilize the portal on Availity.com or fax the Authorization Change Request Form to 1-888-319-6479. This form is NOT intended to add codes to an existing authorization. For approval of additional services, please submit a new authorization request.

To submit a referral in Illinois, go to the authorization portal via Availity.com and click on the “referrals” tab. Providers may also submit a referral via fax.

IFP Provider Services Phone Number: 866-239-7191

Bright HealthCare Data Regarding Approvals and Denials of Prior Authorization Requests
Illinois

Medicare Advantage

Authorization Resources

MA Authorization Fax Form – All services EXCEPT Acupuncture and Chiropractic.

Forms

Submit an authorization to Bright HealthCare for all MA services (except for Acupuncture and Chiropractic services) by submitting electronically via Availity.com or faxing the below form to 1-888-337-2174.

MA Patient Referral Form – All services EXCEPT Acupuncture and Chiropractic.

Authorization Change Request Form - All services EXCEPT Acupuncture and Chiropractic.

Illinois Referral Fax Form.

2022 AIM Resources – Radiology, Radiation Oncology, Genetic Testing

If you need to change a facility name, dates of service or number of units/days on an existing authorization, call 844-926-4522 or fax the Authorization Change Request Form to 1-888-337-2174. This form is NOT intended to add codes to an existing authorization. For approval of additional services, please submit a new authorization request.

MA Fax Number: 1-888-337-2174

MA Provider Services Phone Number: 1-844-926-4522

Submit an authorization to American Specialty Health (ASH) for Acupuncture and Chiropractic services by going to ASH’s website and using their online portal or fax forms.

For questions about an authorization or to change an authorization, contact ASH Provider Services at (800) 972-4226.

American Specialty Health Contact Information:

Provider Services phone number: (800) 972-4226 | Fax Number: (877) 304-2746

Clinical Criteria

Written clinical criteria is available through the provider portal and the member hub

Individual and Family Plans or Small Group

Authorization Resources

To submit authorizations for all services except diagnostic/advanced imaging, radiation oncology, and genetic testing, please either:

Submit electronically via Availity.com (preferred method), OR
Use the below fax forms.

To submit authorizations for diagnostic/advanced imaging, radiation oncology, and genetic testing, please visit AIM’s ProviderPortal, or call AIM at (833) 305-1802, Monday-Friday 7am-7pm CT, excluding holidays. If authorization changes are needed, please use AIM’s ProviderPortal or call their call center. Note: Dates of Service cannot be changed or extended in an authorization.

Forms & Resources

Authorization Change Request Form - All services EXCEPT diagnostic/advanced imaging, radiation oncology, and genetic testing

If you need to change a facility name, dates of service or number of units/days on an existing authorization, utilize the portal on Availity.com or fax the Authorization Change Request Form to 1-888-319-6479. This form is NOT intended to add codes to an existing authorization. For approval of additional services, please submit a new authorization request.

IFP Provider Services Phone Number: 866-239-7191

Small Group Provider Services Phone Number: 855-521-9364

Medicare Advantage

Authorization Resources

MA Authorization Fax Form – All services EXCEPT Acupuncture and Chiropractic.

Forms

Submit an authorization to Bright HealthCare for all MA services (except for Acupuncture and Chiropractic services) by submitting electronically via Availity.com or faxing the below form to 1-888-337-2174.

MA Patient Referral Form – All services EXCEPT Acupuncture and Chiropractic.

Authorization Change Request Form - All services EXCEPT Acupuncture and Chiropractic.

2022 AIM Resources – Radiology, Radiation Oncology, Genetic Testing

If you need to change a facility name, dates of service or number of units/days on an existing authorization, call 844-926-4522 or fax the Authorization Change Request Form to 1-888-337-2174. This form is NOT intended to add codes to an existing authorization. For approval of additional services, please submit a new authorization request.

MA Fax Number: 1-888-337-2174

MA Provider Services Phone Number: 1-844-926-4522

Submit an authorization to American Specialty Health (ASH) for Acupuncture and Chiropractic services by going to ASH’s website and using their online portal or fax forms.

For questions about an authorization or to change an authorization, contact ASH Provider Services at (800) 972-4226.

American Specialty Health Contact Information:

Provider Services phone number: (800) 972-4226 | Fax Number: (877) 304-2746

Individual and Family Plans or Small Group

Authorization Resources

To submit authorizations for all services except diagnostic/advanced imaging, radiation oncology, and genetic testing, please either:

Submit electronically via Availity.com (preferred method), OR
Use the below fax forms.

To submit authorizations for diagnostic/advanced imaging, radiation oncology, and genetic testing, please visit AIM’s ProviderPortal, or call AIM at (833) 305-1802, Monday-Friday 7am-7pm CT, excluding holidays. If authorization changes are needed, please use AIM’s ProviderPortal or call their call center. Note: Dates of Service cannot be changed or extended in an authorization.

Forms & Resources

Authorization Change Request Form - All services EXCEPT diagnostic/advanced imaging, radiation oncology, and genetic testing

If you need to change a facility name, dates of service or number of units/days on an existing authorization, utilize the portal on Availity.com or fax the Authorization Change Request Form to 1-888-319-6479. This form is NOT intended to add codes to an existing authorization. For approval of additional services, please submit a new authorization request.

IFP Provider Services Phone Number: 866-239-7191

Small Group Provider Services Phone Number: 855-521-9364

Individual and Family Plans (IFP)

Authorization Resources

To submit authorizations for all services except diagnostic/advanced imaging, radiation oncology, and genetic testing, please either:

Submit electronically via Availity.com (preferred method), OR
Use the below fax forms.

To submit authorizations for diagnostic/advanced imaging, radiation oncology, and genetic testing, please visit AIM’s ProviderPortal, or call AIM at (833) 305-1802, Monday-Friday 7am-7pm CT, excluding holidays. If authorization changes are needed, please use AIM’s ProviderPortal or call their call center. Note: Dates of Service cannot be changed or extended in an authorization.

2022 AIM Resources – Radiology, Radiation Oncology, Genetic Testing

Forms & Resources

Authorization Change Request Form - All services EXCEPT diagnostic/advanced imaging, radiation oncology, and genetic testing

2022 AIM Resources – Radiology, Radiation Oncology, Genetic Testing

If you need to change a facility name, dates of service or number of units/days on an existing authorization, utilize the portal on Availity.com or fax the Authorization Change Request Form to 1-888-319-6479. This form is NOT intended to add codes to an existing authorization. For approval of additional services, please submit a new authorization request.

IFP Provider Services Phone Number: 866-239-7191

Individual and Family Plans

Authorization Resources

To submit authorizations for all services except diagnostic/advanced imaging, radiation oncology, and genetic testing, please either:

Submit electronically via Availity.com (preferred method), OR
Use the below fax forms.

To submit authorizations for diagnostic/advanced imaging, radiation oncology, and genetic testing, please visit AIM’s ProviderPortal, or call AIM at (833) 305-1802, Monday-Friday 7am-7pm CT, excluding holidays. If authorization changes are needed, please use AIM’s ProviderPortal or call their call center. Note: Dates of Service cannot be changed or extended in an authorization.

Forms & Resources

Authorization Change Request Form - All services EXCEPT diagnostic/advanced imaging, radiation oncology, and genetic testing

2022 AIM Resources – Radiology, Radiation Oncology, Genetic Testing

If you need to change a facility name, dates of service or number of units/days on an existing authorization, utilize the portal on Availity.com or fax the Authorization Change Request Form to 1-888-319-6479. This form is NOT intended to add codes to an existing authorization. For approval of additional services, please submit a new authorization request.

IFP Provider Services Phone Number: 866-239-7191

Individual and Family Plans or Small Group

Authorization Resources

To submit authorizations for all services except diagnostic/advanced imaging, radiation oncology, and genetic testing, please either:

Submit electronically via Availity.com (preferred method), OR
Use the below fax forms.

To submit authorizations for diagnostic/advanced imaging, radiation oncology, and genetic testing, please visit AIM’s ProviderPortal, or call AIM at (833) 305-1802, Monday-Friday 7am-7pm CT, excluding holidays. If authorization changes are needed, please use AIM’s ProviderPortal or call their call center. Note: Dates of Service cannot be changed or extended in an authorization.

Forms & Resources

Authorization Change Request Form - All services EXCEPT diagnostic/advanced imaging, radiation oncology, and genetic testing

If you need to change a facility name, dates of service or number of units/days on an existing authorization, utilize the portal on Availity.com or fax the Authorization Change Request Form to 1-888-319-6479. This form is NOT intended to add codes to an existing authorization. For approval of additional services, please submit a new authorization request.

IFP Provider Services Phone Number: 866-239-7191

Small Group Provider Services Phone Number: 855-521-9364

Individual and Family Plans (IFP)

Authorization Resources

To submit an authorization for all services except medical specialty pharmacy services, please either:

Submit electronically via Availity.com (preferred method), OR
Fax the below Authorization Fax Form to 1-877-438-6832.

Submit authorization requests for medical specialty pharmacy these drugs to Magellan Rx in the following ways:

For non-urgent requests, please contact Magellan Rx through the provider portal or by phone:

Provider portal: If the provider contracts directly with Bright HealthCare, log on to MRxGateway.com and click Request Prior Authorizations
Phone: Call Magellan Rx at 800-424-2804* weekdays between 8:00 a.m. and 6:00 p.m. local time.

For urgent requests**, please call Magellan Rx at 800-424-2804*. Lines are open 24 hours a day, 7 days a week.

Forms & Resources

Texas Gold Card FAQ

If you need to change a facility name, dates of service or number of units/days on an existing authorization, call 844-926-4525 or fax the Authorization Change Request Form to 1-877-438-6832. This form is NOT intended to add codes to an existing authorization. For approval of additional services, please submit a new authorization request.

IFP Provider Services Phone Number: 844-926-4525

Individual and Family Plans (IFP)

Authorization Resources

To submit an authorization for all services except medical specialty pharmacy services, please either:

Submit electronically via Availity.com (preferred method), OR
Fax the below Authorization Fax Form to 1-877-438-6832.

Submit authorization requests for medical specialty pharmacy these drugs to Magellan Rx in the following ways:

For non-urgent requests, please contact Magellan Rx through the provider portal or by phone:

Provider portal: If the provider contracts directly with Bright HealthCare, log on to MRxGateway.com and click Request Prior Authorizations
Phone: Call Magellan Rx at 800-424-2804* weekdays between 8:00 a.m. and 6:00 p.m. local time.

For urgent requests**, please call Magellan Rx at 800-424-2804*. Lines are open 24 hours a day, 7 days a week.

Forms & Resources

If you need to change a facility name, dates of service or number of units/days on an existing authorization, call 844-926-4525 or fax the Authorization Change Request Form to 1-877-438-6832. This form is NOT intended to add codes to an existing authorization. For approval of additional services, please submit a new authorization request.

IFP Provider Services Phone Number: 844-926-4525

Individual and Family Plans (IFP)

Authorization Resources

To submit an authorization for all services except medical specialty pharmacy services, please either:

Submit electronically via Availity.com (preferred method), OR
Fax the below Authorization Fax Form to 1-877-438-6832.

Submit authorization requests for medical specialty pharmacy these drugs to Magellan Rx in the following ways:

For non-urgent requests, please contact Magellan Rx through the provider portal or by phone:

Provider portal: If the provider contracts directly with Bright HealthCare, log on to MRxGateway.com and click Request Prior Authorizations
Phone: Call Magellan Rx at 800-424-2804* weekdays between 8:00 a.m. and 6:00 p.m. local time.

For urgent requests**, please call Magellan Rx at 800-424-2804*. Lines are open 24 hours a day, 7 days a week.

Forms & Resources