Precertification Request Form

Welcome to the online certification portal. This online certification process is designed to improve the response time for completing your request for review.

The information you may be asked to provide is required to ensure the accuracy of your request and to prevent unnecessary delays in the review process.

If you have an urgent/emergent case please call (888) 886-4877.

Please have the following information available before you begin:

  • Member Identification number
  • Patient’s full name, address, and phone number
  • Diagnosis code(s)
  • CPT codes (if applicable)
  • Admitting/Ordering physician’s full name, address, phone number and tax ID
  • Facility name, address, phone number and tax ID

If additional information is needed to complete the review, you will be contacted. After the review has been completed, you will be contacted regarding the outcome of your request.