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Prior authorization

Prior authorization (PA) is required for some out-of-network providers, outpatient care and planned hospital admissions. We don’t require PA for emergency care. You can find a current list of the services that need PA on the Provider Portal. You can also find out if a service needs PA by using ProPAT, our online prior authorization search tool.


Search ProPAT



Check out your provider manual. Or contact us.

Tips for requesting PA

Tips for requesting PA

A request for PA doesn’t guarantee payment. We can’t reimburse you for unauthorized services. You can make requesting PA easier with these tips:


  • Register for Availity if you haven’t already.
  • Verify member eligibility before providing services.
  • Based on the type of request, complete and submit the PA request form.

  • Attach supporting documents when you submit the form.

How to request PA


Ask for PA through our Provider Portal.

By phone

Ask for PA by calling us:  


By fax

Download and complete the PA request form based on the type of request. Add any supporting materials for the review. Then, fax it to us.


Fax numbers for PA request forms 


  • Physical health PA request form fax: 1-860-607-8056 

  • Behavioral health PA request form fax (Medicaid Managed Medical Assistance): 1-833-365-2474

  • Behavioral health PA request form fax (Florida Healthy Kids): 1-833-365-2493

Utilization management (UM)

The purpose of UM is to review eligibility for benefits for the care that has been or will be provided to patients. The UM department is composed of: 


  • Preauthorization 

  • Concurrent review 

  • Case management  


Medical necessity is based upon clinical standards and guidelines as well as clinical judgment. All clinical standards and guidelines used in the UM program have been reviewed and approved by practicing, participating physicians in our network.  


Need a copy of our clinical standards and guidelines? Just call us at 1-800-441-5501 (TTY: 711), 7:30 AM to 7 PM, Monday through Friday. 

The medical director makes all final decisions regarding the denial of coverage for services when the services are reviewed via our UM program. The provider is advised that the decision is a payment decision and not a denial of care. The responsibility for treatment remains with the attending physicians.


The policy on payment for services helps ensure that the UM decision-making process is based on consistent application of appropriate criteria and policies rather than financial incentives.


UM decision-making is based on:


  • Appropriateness of care

  • Service 

  • Existence of coverage


Adverse decisions


The medical director is available to discuss denials with attending physicians and other providers during the decision process. Notification of the decision includes:


  • The criteria used and the clinical reason(s) for the adverse decision

  • Instructions on how to request reconsideration 

  • A contact person’s name, address and telephone number for requesting reconsideration


We do not reward practitioners, providers or employees who perform utilization reviews, including those of the delegated entities, for issuing denials of coverage or care. The compensation that we pay to practitioners, providers and staff assisting in utilization-related decisions does not encourage decisions that result in underutilization or barriers to care or service.

Want to learn more? You can contact our UM staff if you need help or have any questions related to a specific case. You can get help 8 AM to 7 PM, Monday through Friday.



For questions after hours or during weekends or holidays, just leave a voicemail or fax. We’ll return your message.

Pharmacy PA

Want to learn more about pharmacy PA? Just visit our pharmacy PA page.


Pharmacy prior authorization


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