Requesting Authorization

Information for Requesting Authorizations    

For some medical services, PCPs and Providers must request referrals and prior authorizations on behalf of Members. Specialists should submit requests for further care after the initial visit. In Tier 1, these requirements are minimal when Members receive care from Prime Providers and Facilities.

When authorizations are required, they must be approved by Prime Utilization Management before Members receive care. Prime has made these approvals faster and easier than ever.

In general, services and supplies must be Medically Necessary for the care and treatment of a covered Sickness, Accidental Injury, Pregnancy or other covered health care condition. To determine medical necessity, contact Prime at 877-234-5227 or fax clinical to Prime UM 909-235-4414.

Through our online Prime Authorization System (PAS), 60 percent of requests are approved instantly. 96 to 98 percent are approved overall with 92 percent approved within 24 hours.

If you don’t already have PAS access and want to request prior authorization via fax, please click here to download the form. To request a PAS application login, email PASLOGIN@Primehealthcare.com with your group name and tax ID.

To download and review the most recent Authorization Process and comprehensive list of services that do not need prior authorization when rendered by a Tier1 Specialist (effective 3/1/2023), click here.