Preauthorization Forms and Lists

Preauthorization Request Forms

Preauthorization forms must be submitted when not using CareAffiliate or PromptPA.

Access the relevant request form for your practice using the table below.

Utah & Idaho

All Commercial Plans, Select Health Medicare

Select Health Community Care® (Medicaid) in Utah only 


Select Health Med® Network

Select Health Medicare


Select Health Value

Select Health Medicare Advantage

 Request for Medical Preauthorization

Behavioral Health-Related Preauthorization--Initial Request

Learn more about services/procedures requiring preauthorization.

Use PromptPA for prescription and durable medical equipment preauthorization requests. 


Preauthorization Requirements Lists

View the current list of services/procedures requiring preauthorization based on the relevant member coverage type:

Access non-covered codes (or those covered with preauthorization requirements) by state and plan type*: 

       Download Using Online Covered-Codes Files for tips on quickly searching for the information you need.

* This information is updated quarterly and subject to plan specifics. For questions, contact Member Services at 800-538-5038.