CBG Medical Prior Authorization Form

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 Name*

First NameLast Name

Patient ID #*

Member ID Number

Group ID #*

Group ID Number

Date of Birth*

Date

Gender (Optional)

MF

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. If a reference number is needed for documentation purpose that an authorization is not required: Please use COBALT2025.)

• ABA Therapy

• Colonoscopy – *ONLY required for Group # 80867

o Both screening and diagnostic, including anesthesia – regardless of rendering location

• Diagnostic Imaging (CT/CTA, MRI/MRA/MRCP, PET, Nuclear Med) *Only required for the following three groups:

o Group # 50632

o Group # 50628

o Group # 80867

o All other groups do NOT require pre-cert:

• ECHO - Echocardiogram/Stress Echo

• EKG - Electrocardiogram

• EEG – Electroencephalogram

• EGD – Endoscopy/Capsule Endoscopy - *Only required for Group # 80867

o Including anesthesia -regardless of rendering location

• EMG - Electromyography

• Holter Monitor/XIO Patch

• Injections - *ONLY required for the following groups:

o Group # 10894 over $1000

o Group # 10778 over $1000

o 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

• Varicose Vein Treatment

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 to the number provided on the request.)

• Anesthesia and Facility Charges for Dental Only

• Bariatric surgery

• Blepharoplasty

• Breast reduction

• Chemotherapy

• Cosmetic services

• Dialysis

• DME - Durable Medical Equipment/Prosthetics (Please Include Purchase price/invoice)

• Formula and food products

• Gender Identity related services

• Genetic Testing

• Home Health/Hospice

• Infertility treatment (All services)

• Infusions – Outpatient and Home

• Inpatient Admissions

• Panniculectomy

• Radiation Treatment

• Septoplasty/Sinuplasty/Rhinoplasty

• SNF/Acute Rehab/LTAC Admissions

• Transplant services

When applicable, include supporting chart notes, diagnostic tests, and lab values.*

Rendering Provider Name*

Rendering Provider Name

NPI #*

Rendering Provider NPI Number

Tax ID*

Rendering Provider Tax ID Number

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

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.

DX Code(s)*

Primary Description*

Start Date of Service*

Start Date

End Date of Service*

End Date

Code(s)*

Units/Visits if Applicable

Units/Visits

Overall Description*

Clinical Files Required*

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.

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