Please allow 3-5 business days for the sharing determination to be made. For urgent requests, please select urgent request below. Please be advised that pre-eligibility is required only for non-emergent procedures/medical expenses. If member requires emergent services, please proceed without submitting a pre-eligibility request and eligibility will be determined post-procedure.
Urgent Request (response within 72 hours)
Email address for confirmation of Pre-Eligibility request *
Membership ID *
Member First Name *
Member Last Name *
Member DOB *
Facility Name *
Facility Address 1 *
Facility Address 2
Facility City *
Facility State *
Facility Zip *
Facility Tax ID *
Facility Phone # *
Facility Fax #
Provider's Full Name *
Provider NPI *
Provider Tax ID *
Provider Phone # *
Provider Fax #
Provider Contact *
Diagnosis or Chief complaint *
CPT codes/Services to be rendered *
If maternity:
LMP (Last menstrual period date)
EDD (Estimated due date)
Date of Service
Email or fax number where eligibility response is to be sent *
Please provide patient's medical records pertaining to this pre-authorization request