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Submit a Prior Authorization

FOR MEDICAL PROFESSIONAL USE ONLY

Prior Authorization Instructions

Prior authorization (PA) is required before certain services are rendered to confirm medical necessity. No PA is required for emergency or transportation services. All services for out-of-network providers, except emergency services, require prior authorization. Criteria utilized in decision making can be accessed through the secure provider portal.

How to Request a Prior Authorization

Vendor SolutionsVendor Links
DentalEnvolve Dental
MRA, MRI, PET, CT Scans, and Cardiac ImagingEvolent
Pain ManagementEvolent
Speech, Occupational and Physical TherapyEvolent
Musculoskeletal ServicesEvolent
Non-Emergent Non-Ambulance TransportationMTM
fm.formularynavigator.com,medicare.entrykeyid.com,member.membersecurelogin.com,mmp.ilmeridian.com,findaprovider.mmp.ilmeridian.com,provider.mmp.mimeridian.com,

Updated Date: 10/01/24

H6080_WEBSITE_2025_Accepted_09302024


Updated Date: 10/01/24

H6080_WEBSITE_2025_Accepted_09302024