Authorizations

​Certain specialized services and prescription drugs require a prior authorization or inpatient notification before being rendered to patients and members. Prior authorizations and inpatient notifications ensure that patients are receiving the right amount of medically necessary care in the right setting for the insurance plan for which they're enrolled.

Medical

• Prior Authorization Guide
• Intel Connected Care Prior Authorization Grid
• Prior Authorization Request Form
  
• VBID Transitional Services Request Form
  
• VBID Fact Sheet and FAQs
  
• Referral Form: Care Coordination/Case Management/Disease Management
• Notice of Medicare Non-coverage Form
  
• Notice of Medicare Non-coverage Form (Spanish)
  
• Notice of Medicare Non-coverage Presbyterian Dual Plus Form
  
• Important Information Regarding Your Hospice Services, Presbyterian Senior Care (HMO) Plans 1, 2 and 3 only
  

Fax completed Prior Authorization form to Presbyterian at:

• Prior Authorization (505) 843-3047
• Inpatient Utilization Management (505) 843-3107
• Home Health Care (505) 559-1150
• UNM Prior Authorization (505) 843-3108

- OR -

Complete and submit Prior Authorization online

Pharmacy

For the most up-to-date formulary drug information access the Provider Formularies page. Formulary drug coverage status and additional restrictions are listed in the plan’s formulary (drug list).

Provider Formularies

Fax completed Prior Authorization forms to Presbyterian Pharmacy Services at (505) 923-5540 or at 1-800-724-6953.

- OR -

Complete and submit Prior Authorization online

Advanced Imaging Ordering Program

Presbyterian uses the Medical Specialty Solutions (MSS) program, managed by National Imaging Associates, Inc. (NIA), for prior authorizations of both non-emergent, advanced diagnostic imaging procedures and cardiac-related imaging procedures performed in an outpatient setting. The program is designed to streamline the authorization process, reduce healthcare costs, and improve patient outcomes. The documents below provide additional information about the MSS program. If you have any questions or concerns about the program, please contact your Provider Network Management relationship executive.

View clinical criteria, timelines, and submit a prior authorization request for advanced imaging

• General Frequently Asked Questions (FAQs)
• Quick Reference Guide
• Utilization Review Matrix
• Announcement for Cardiac Providers
• Cardiac-Related Frequently Asked Questions (FAQs)
• Checklist for Cardiac Providers

Behavioral Health

• Prior Authorization Guide
• Prior Authorization Request Form
• Behavioral Health Medical Necessity Criteria (Medicare/Commercial)
• Centennial Care Concurrent Clinical Review Form
  
• Centennial Care Discharge Clinical Notification Form
  
• Centennial Care Initial Clinical Review Form
  
• Centennial Care Retrospective Clinical Review Form
  
• Applied Behavior Analysis (ABA) Clinical Review Form: Stage 3
  
• Applied Behavior Analysis (ABA) Specialty Care Clinical Review Form
  

Fax completed Prior Authorization form to Presbyterian at:

• Centennial Care BH: (505) 843-3019
• Medicare/Commercial BH: 1-888-656-4967

- OR -

Complete and submit Prior Authorization online (Medicare/Commercial)
Complete and submit Prior Authorization online (Centennial Care only)

Need Assistance? 

For assistance with Prior Authorization or Utilization Management issues please call 505-923-5757 or 1-888-923-5757. We may be reached using this number both during and after normal business hours.