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.
Providers are required to verify member benefits and precertification requirements through the Provider Portal prior to submission. Click Here: Cobalt Benefits Group | Provider Portal

If a form is submitted for a member or service that does not require precertification, no response or fax will be provided. Benefit and precertification information is available in the Provider Portal and must be reviewed before submitting requests.

Please ensure all submissions meet precertification requirements to avoid delays or no response.
Group ID #*
Group ID Number
Please call 877-284-0102 for precertification.
Please call 877-608-2200 for precertification.
Please call 866-678-0761 for precertification.
Please call 866-499-5102 for precertification.
Please call 866-678-0761 for precertification.
Please call 866-499-5178 for precertification.

Urgent Request
Patient Name*

First NameLast Name
Patient ID #*
Member ID Number
This information will be sent to the UR department for clinical review. They will contact 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.

Please ensure all submissions meet precertification requirements to avoid delays or a non-response.

Important Note regarding Chemo/Radiation:

Please be advised that the typical turnaround 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 in a timely manner will result in a delay of authorization. Chemo and radiation treatment cannot and will not be authorized within 24 to 48 hours.
Patient Information
Date of Birth*

MonthDayYear
Date
MF
Requested Service

If procedure is not listed below, please call before submitting form to confirm if prior authorization is necessary.
Please select the service you are requesting precertification for, or select "None of the Above."
This outpatient service does not require review. If you submit a request for this service, 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 COBALT2026
This outpatient service only requires review for Group ID# 10894 or 10778 over $1000, or 80875 over $2000. If the patient has one of those group numbers, please select the appropriate option above. Otherwise, pre-cert is not required. If you submit a request for this service, 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 COBALT2026
This outpatient service only requires review for Group ID# 80867. If the patient has one of those group numbers, please select the appropriate option above. Otherwise, pre-cert is not required. If you submit a request for this service, 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 COBALT2026
This outpatient service only requires review for Group ID# 80867, 80923, or 80926. If the patient has one of those group numbers, please select the appropriate option above. Otherwise, pre-cert is not required. If you submit a request for this service, 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 COBALT2026
This outpatient service only requires review for Group ID# 80867 or 50628. If the patient has one of those group numbers, please select the appropriate option above. Otherwise, pre-cert is not required. If you submit a request for this service, 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 COBALT2026
DME Purchase Price
Emergency Inpatient AdmissionScheduled Inpatient AdmissionResidentialOutpatientLTACAcute RehabHome HealthSNFDurable Medical Equipment
For Emergency Inpatient Admissions, if you do not have Clinical Notes available at this time, please fax Clinical Notes as soon as possible to the fax number listed below. We cannot review without Clinical Notes.

Blue Benefit Administrators (BBA) 978-332-5113

CBA Blue VT / EBPA 802-846-2702
Rendering Provider Information

Please enter the ordering MD's 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

For inpatient admissions, please provide the UR 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.Format: (000) 000-0000.
UR/Facility Fax Number*
Please enter a valid phone number.Format: (000) 000-0000.
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