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Forms and resources for health care professionals

Home Health Care prior authorization intake request form

View the prior authorization request form for the Connecticut, Indiana, and Ohio market.

Optum-WA physician/provider change form

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.

Utilization management program description

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.

Hub referral card

How to refer your patients with multiple sclerosis.

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 specialty 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.

Standard personal health information (PHI) authorization form

Complete and return this form to give your permission to discuss and/or release your PHI to a person who is your Authorized Representative.

Request for confidential communications at an alternative address

Please complete and return the form to the requesting department.

Request to amend protected health information (PHI)

Please complete and return the form to the requesting department.

Request for record of non-routine disclosures of protected health information

Please complete and return the form to the requesting department.

Notice of privacy practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Neuromuscular disorder referral form

Optum specialty referral form for neuromuscular disorders. Send us the form and we will take care of the rest.

Dermatology referral form

Optum specialty referral form for Dermatology. Send us the form and we will take care of the rest.

Advance beneficiary notice of noncoverage (ABN)

Please complete and return the form to the requesting department.

Fertility general referral form

Optum specialty fertility referral form. Send us the form and we will take care of the rest.

Advance beneficiary notice of noncoverage (ABN)

Please complete and return the form to the requesting department.

General referral form

General Optum specialty referral form. Send us the form and we will take care of the rest.

Request to restrict use and disclosure of protected health information

Please complete and return the form to the requesting department.

Oncology referral form

Optum specialty referral form for oncology. Send us the form and we will take care of the rest.

Authorization to use and disclose protected health information

Please complete and return the form to the requesting department.

Immunoglobulin referral form

Optum Infusion Pharmacy IVIG and SCIG referral/enrollment form. Send us the referral and we will take care of the rest.

Synagis referral form

Optum Specialty RSV referral form for Synagis.

Neuromuscular disorder referral form – migraine, cervical dystonia, overactive bladder

Optum specialty referral form. Send us the form and we will take care of the rest.

Request to amend protected health information

Please complete and return the form to the requesting department.

Biologics infusion referral form

Complete and return this form to refer a patient for biologic infusion therapy with Optum Infusion Pharmacy.

Request for access to protected health information

Please complete and return the form to the requesting department.

Pulmonary arterial hypertension referral form

Optum specialty referral form for pulmonary arterial hypertension (PAH). Send us the form and we will take care of the rest.

Osteoarthritis referral form

Optum specialty referral form. Send us the form and we will take care of the rest.

Notice of privacy practices

Please complete and return the form to the requesting department.

Hemophilia and bleeding disorders referral form

Optum Infusion Pharmacy referral/enrollment form for hemophilia and bleeding disorders. Send us the referral and we will take care of the rest.

Oncology REMS referral form

Optum specialty referral form for REMS oncology medications. Send us the form and we will take care of the rest.

IV anti-infectives referral form

Optum Infusion Pharmacy referral/enrollment form for antibiotics. Send us the referral and we will take care of the rest.

Request for confidential Optum Infusion Pharmacy communications at an alternative address or by another means

Please complete and return the form to the requesting department.

Home parenteral nutrition referral form

Optum Infusion Pharmacy referral/enrollment form for parenteral nutrition. Send us the referral and we will take care of the rest.

Request to restrict use and disclosure of protected health information

Please complete and return the form to the requesting department.

Opioid antagonist referral form

Optum specialty referral form. Send us the form and we will take care of the rest.

Osteoporosis referral form

Optum specialty referral form. Send us the form and we will take care of the rest.

Rheumatology referral form

Optum specialty referral form for Rheumatology. Send us the form and we will take care of the rest.

Neuromuscular disorder referral form– achalasia, chronic anal fissure, fetrusor overactivity, spasticity, bleopharospasm

Optum specialty referral form. Send us the form and we will take care of the rest.

Provider dispute resolution forms

Use these forms for the Optum Care Network–Utah.

Provider dispute resolution forms

Use these forms for the Washington market.

Claims provider manual

Our provider claims guide offers our network providers key information and support in submitting claims.

Provider dispute resolution forms

Use these forms for the New Mexico market.

Arizona Chemotherapy Drug Prior Authorization

Learn more about the prior authorization process.

Direct admit to SNF form

Complete this form to initiate an admission to a skilled nursing facility (SNF).

Provider lookup tool

Find doctors in Arizona.

Primary care provider referral form

View the Optum Care–Utah provider referral form.

Prior authorization list

Get a list of codes for the Optum Care–Colorado.

Specialist referral form

Get a referral form for specialists in Arizona.

Provider dispute resolution forms

Use these forms for the Indiana market.

Provider dispute resolution forms

Use these forms for the Nevada market.

Provider dispute resolution forms

Use these forms for the Ohio market.

Provider dispute resolution forms

Use these forms for the New York market.

Provider dispute resolution forms

Use these forms when working with patients in Colorado.

Provider dispute resolution form - CT

Challenge, appeal or request reconsideration of a claim.

Washington Provider Manual

Our provider guide offers our network providers key information and support to provide effective care in the Washington market.

Provider dispute resolution forms

Use these forms for the Oregon market.

Washington quick reference guide

Get important details for the Washington market.

Prior authorization list (UHC)

Get a list of codes for Optum Care-Arizona (UHC Members).

Prior authorization grid

View a list of CPT codes requiring a prior authorization for Indiana, Ohio and New York.

Evidence in action

Get a closer look at how evidence is advancing life sciences.

Alpha-1 referral form

Optum Infusion Pharmacy referral/enrollment form for alpha-1 proteinase inhibitor therapy

Optum Clinical Claims Review (CCR) Pre-Pay Review Quick Reference Guide

Learn about the CCR pre-pay review process

Provider dispute resolution form

Use these forms for the Kansas City market.

Optum Care ACE Smart Edits

Learn more about the Advanced Communication Engine and the edits currently in place.

Optum Care ACE quick reference guide

Get important details about the Advanced Communication System.

Provider quick reference guide

Get important details for the Ohio market.

Optum-WA/OR care management referral form

This is a form for fax submissions.

Provider dispute resolution form

Challenge, appeal or request reconsideration of a claim.

Provider dispute resolution request

Complete this form to request a dispute resolution.

Prior authorization grid

View a list of CPT codes requiring a prior authorization for Wisconsin.

Provider dispute resolution forms

Use these forms for the South Carolina market.

Online prior authorization submissions

View important benefits of submitting prior authorizations online using the prior authorization module (Curo)

Provider dispute resolution forms

Use these forms for the Wisconsin market.

Multiple sclerosis referral form - Infusion

Optum Infusion Pharmacy referral form for multiple sclerosis. Send us the form and we will take care of the rest.

Prior authorization grid South Carolina

View a list of CPT codes requiring a prior authorization for South Carolina.

Arizona radiation therapy prior authorization

Learn more about the prior authorization process.

Prior authorization requirements for Optum Care Network–New Mexico

View the prior authorization process for New Mexico.

Benzodiazpines Prior Authorization Form

This is a Medicare form for benzodiazepines prior authorization requests.

Prior authorization grid

View a list of CPT codes requiring prior authorization for Idaho

Medicare Part D Prior Authorization for Hospice Form

Use this form for hospice enrollees.

Prior authorization grid

View a list of CPT codes requiring prior authorization for Utah

Prior Authorization Request Form

This is a Medicare form for general PA requests.

Opioids & Medication Limits Prior Authorization Request Form-UnitedHealthcare Medicare only

Please use this form for all opioid requests including MME exceeded, concurrent uses, quantity limits.

Prior authorization grid

View a list of CPT codes requiring prior authorization for Kansas City.

Opioids & Medication Limits Prior Authorization Request Form

Please use this form for all opioid requests including MME exceeded, concurrent uses, quantity limits.

Prescription Drug Reference Pricing Program

This form is for UFCW Plans only.

Delaware Prior Authorization Form

The form is for UnitedHealthcare (non-Medicare).

State of Arizona prior authorization form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Texas Prior Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Partial Copay Waiver (PCW) Exception Prior Authorization Request Form

This is for CalPERS Plan only.

Prior Authorization Form UHC

This form is for UnitedHealthcare (non-Medicare).

Massachusetts Prior General Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Colorado Prior Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Florida Prior Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Healthcare Reform Copay Waiver Request Form

This for is for UnitedHealthcare (non-Medicare).

New Mexico Prior Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Massachusetts Chemotherapy and Supportive Care PA Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Prior authorization supporting documentation cover sheet

View the supporting documents (medical records) cover page for New Mexico

Michigan Prior Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Illinois Prior Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Member Pays Difference Exceptions PA Form

This form is for CalPERS Plan only.

Prior authorization supporting documentation cover sheet

View the supporting documents (medical records) cover page for Connecticut

New Hampshire Prior Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Prior authorization supporting documentation cover sheet

View the supporting documents (medical records) cover page for Indiana, Ohio, and New York

Prior authorization supporting documentation cover sheet

View the supporting documents (medical records) cover page for Washington

Prior Authorization Request Form

Use this form for Emergient North Dakota plan only.

Massachusetts Hepatitis-C Medications Prior Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Prior Authorization Request Form

Use this form for Emergient Vermont Plan only.

Healthcare Reform Copay Waiver Request Form

This is for OptumRx (non-Medicare).

State of California prior authorization form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Oregon Prior Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Optum Provider Change Form

Please use this form to request demographic updates, remit address changes, or updates to your practice information.

UHC West of California delegated medical group auto-authorization form

This form for UnitedHealthcare (non-Medicare).

Massachusetts Synagis Prior Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Minnesota Prior Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Prior authorization supporting documentation cover sheet

View the supporting documents (medical records) cover page for Oregon

Cancer Guidance Program Contract Termination

Provider notification of change in how authorization is obtained for chemo therapy drugs

Louisiana Prior Authorization Form

This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).

Prior authorization supporting documentation cover sheet

View the supporting documents (medical records) cover page for Arizona, Colorado, Idaho, Kansas City, Nevada, and Utah

Rhode Island Prior Authorization Form

This form is for UnitedHealthcare (non-Medicare).

EDI Companion Guide

HIPAA Companion Guides describe Optum Rx specific technical details for EDI transactions.

Provider dispute resolution form - APN

Challenge, appeal or request reconsideration of a claim.

Prior authorization request form

View the prior authorization request form for the Indiana, New York and Ohio markets.

Submitting an electronic prior authorization (e-PA)

Prior authorization list (BCBS)

Get a list of codes for Optum Care-Arizona (BCBS Members).