CBG Medical Prior Authorization Form

Medical Prior Authorization Form

The fields marked with an asterisk (*) are required. The authorization process will be delayed if the request form is incomplete.
Please select if this is an urgent request.

Urgent Request
This information will be sent to the UR department for clinical review, they will call you with a precertification number and to request additional information if necessary.
If you are submitting this on a weekend or holiday and our member is medically cleared by the doctor for transfer to a Skilled Nursing Facility or Acute Rehab, please proceed with the transfer. We will review the clinical documentation the next business day.

Important Note regarding Chemo/Radiation:

Please be advised that the typical turn-around time for review for chemo and/or radiation treatments can be upwards of 30 days and often require different levels of review while in Case Management. Failure to submit information timely will result in a delay of authorization. Chemo and radiation treatment cannot and will not be authorized within 24 to 48 hours.
Patient Information
Patient Name*

First NameLast Name
Patient ID #*
Member ID Number
Group ID #*
Group ID Number
Date of Birth*

MonthDayYear
Date
Gender (Optional)

MF
Requested Service

If procedure is not listed below, please call before submitting form to confirm if prior authorization is necessary.
Please Note,

The following OUTPATIENT services DO NOT require review: (if you submit a request for any of these services, you WILL NOT receive a response as pre-cert is not required.)
• ABA Therapy
• Colonoscopy (only required for group # 80867)
Both screening and diagnostic, including anesthesia – regardless of rendering location
• Echocardiogram (ECHO)/Stress Echo
• Electrocardiogram (EKG)
• Electroencephalogram (EEG)
• Capsule Endoscopy EGD (*only required for Group # 80867)
Regardless of rendering location
• Holter Monitor/XIO Patch
• Injections - *ONLY required for the following groups:
Group # 10894 over $1000
Group # 10778 over $1000
Group # 80875 over $2000
• Labor & Delivery – we follow the Federal Mandate - 48 hours (vaginal), 96 hours (c-section) from time of delivery.
• Observation Admits (OBS)
• PHP/IOP
• Sleep Study/Home Sleep Test/Polysomnogram
• Transcranial Magnetic Stimulation (TMS)
• Ultrasounds (unless connected to infertility)
• X-Rays

Please submit your requests for the following services and/or procedures. (If you submit a request for any of these services, a response will be sent via fax.)

• Bariatric surgery
• Blepharoplasty
• Chemotherapy
• Cosmetic services
• Diagnostic Imaging (CT, MRI, PET, Nuclear Med – most of our plans don’t require)
• Dialysis
• Durable Medical Equipment (DME)/Prosthetics (please include purchase price/invoice)
• Formula and food products
• Gender Identity related services
• Genetic Testing
• Infertility treatment (ALL)
• Infusions – Outpatient and Home (ALL)
• Inpatient Admissions
• Panniculectomy
• Radiation Treatment
• Septoplasty/Sinuplasty/Rhinoplasty
• SNF/Acute Rehab/LTAC Admissions
• Transplant services
• Varicose Vein Treatment
When applicable, include supporting chart notes, diagnostic tests, and lab values.*

Emergency Inpatient AdmissionScheduled Inpatient AdmissionResidentialOutpatientLtacAcute RehabHome HealthSNFDurable medical Equipment
Rendering Provider Information
Rendering Provider Name*
Rendering Provider Name
NPI #*
Rendering Provider NPI Number
Tax ID*
Rendering Provider Tax ID Number
Servicing Location Information

Please provide the information for the Location/Facility where services will be rendered
Servicing Location/Facility Name*
Name of Location/Facility where services will be rendered
Facility Tax ID #*
Services location TIN
Facility NPI #*
Services location NPI Number
Contact Information
We will reach out if our UR departments has questions, Please provide a good contact for us.

Once the case is reviewed, a decision will be faxed to the number provided.
Contact Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
UR/Facility Fax Number*
Please enter a valid phone number.
Diagnosis: ICD Code and Description
DX Code(s)*
Primary Description*
Start Date of Service*

MonthDayYear
Start Date
End Date of Service*

MonthDayYear
End Date
Procedure: CPT Code/HCPCS and Description
Code(s)*
Units/Visits if Applicable
Units/Visits
Overall Description*
Clinical Files Required*

Cancelof
AN AUTHORIZATION DOES NOT ENSURE COVERAGE OR SUPERSEDE ANY MEMBER BENEFIT LIMITS.
Please remember this is not a guarantee of benefits. All benefits are based on medical necessity, clinical review, eligibility, and all other plan provisions that apply such as network status.
Should be Empty:

Medical Prior Authorization Form

Patient Information

Requested Service

Rendering Provider Information

Servicing Location Information

Contact Information

Diagnosis: ICD Code and Description

Procedure: CPT Code/HCPCS and Description