Service Authorization

Service Authorizations are needed for some services before PrimeWest Health will cover them for participating providers. Service Authorizations are required for most services for non-participating providers.

Service Authorizations will only be issued when medical necessity for health care services and products is established and the services/products fall within the criteria or guidelines for the member's benefit set.

Please note: PrimeWest Health has 10 business days to respond to a current request and 30 days to respond to a retroactive request. Please do not call to check on the status of the request or re-fax the same request as it creates larger volumes and actually slows down our response time. PrimeWest Health will call you with our determination within the allotted time frame.

Please see the Authorization chapter of the Provider Manual for more information.

Service Authorization Forms

• Inpatient – Admission Authorization Request
• Enteral Nutrition Service Authorization
• Dialectical Behavior Therapy (DBT) Authorization Request Form
• Medical Service Authorization Request Form
• Service Authorization – Synagis
• Children's Residential Mental Health Treatment Facility Notification
• Mental Health-Targeted Case Management (MH-TCM) Service Authorization Request Form
• Care Coordination Tier Assessment Tool