Optumrx prior auth form for medication
Please use this form to request demographic updates, remit address changes, or updates to your practice information.
Diabetes management (DM) process
This document describes the process for providing diabetes disease management program services to members.
Prior authorization request form
Use this form to request prior authorization of necessary services in Oregon. To view prior authorization requirements, refer to UHC Medicare Advantage Prior Auth Guidelines.
Pre-service peer-to-peer requests
Find guidelines for requesting a peer-to-peer discussion.
Prior authorization request form
Use this form to request prior authorization of necessary services in Washington. See the prior authorization grid for a list of this year's services.
This document describes the program and how it works.
Prior authorization request form
Use this form to request prior authorization of necessary services in New Mexico. See the prior authorization grid for a list of this year's services.
Inter-rater reliability
This document covers how to do annual IRR training for prior authorization clinical staff.
Out-of-network determinations
Find instructions on how to review these requests.
Utilization decision criteria
Optum uses decision-making criteria that are objective, measurable and evidence based.
Care transition procedures
This document defines the process for discharging and safely transitioning Medicare Advantage patients from an inpatient facility.
Quality of care grievance process
Learn how to report concerns about quality of care.
Subdelegation and vendor oversight
This document outlines the review process.
Prior authorization request form
Use this form to request prior authorization of necessary services in Connecticut. See the prior authorization grid for a list of this year's services.
Short-term case management (STCM) process
This document outlines STCM services.
Member satisfaction survey process
Learn the steps to evaluate members' satisfaction and complaints.
Appeal information request policy
This policy outlines the process for sending denial documents to the health plan or QIO for appeal consideration.
Complex case management (CCM) process
This document outlines the steps involved in identifying, educating and helping these patients.
Utilization review procedure
This document identifies benchmarks for patient care.
Provider-member program awareness
This document specifies how providers and members are made aware of Optum Care–Kansas City case and disease management programs and services.
Gastroenterology referral form
Optum specialty referral form. Send us the form and we will take care of the rest.
Connecticut Prior Authorization Alert (OCN)
Reference for obtaining Prior Authorization lists and guidelines.
Third party/donor referral form
Optum specialty referral form for donors and third party fertility patients.
Patient consent and assignment of benefits (AOB)
Please complete and return the form to the requesting department.
Multiple sclerosis referral form
Optum referral form for multiple sclerosis. Send us the form and we will take care of the rest.
Immune globulin therapy enrollment form
Optum specialty referral/enrollment form for immune globulin. Send us the form and we will take care of the rest.
Request for access to protected health information
"Complete and return this form if you would like to access and inspect the information Optum Specialty Pharmacy maintains and uses to make decisions about the services we provide you. "
Hepatitis C referral form
Optum specialty referral form for hepatitis C patients. Send us the form and we will take care of the rest.
Complete and return this form to give your permission to discuss and/or release your PHI to a person who is your Authorized Representative.
