Notification is required for any date of service change. Expedited Requests: If the standard time for making a determination could seriously jeopardize the life and/or health of the member or the …

BEHAVIORAL HEALTH SERVICES Pre-Authorization OP/IP Fax: 713.576.0939 Providers must submit the Prior Authorization Request Form. The form must include the following information:

An Issuer may also provide an electronic version of this form on its website that you can complete and submit electronically, through the issuer’s portal, to request prior authorization of a health care service.

Prior Authorization Fax Form Fax to: 855-537-3447 Request for additional units. Existing Authorization Units Standard and Urgent Pre-Service Requests - Determination within 3 calendar days (72 hours) …