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​Forms to Submit Prior Authorization Requests

• Submit request via Epic Link whenever possible.
• Fax a completed Prior Autho​rization Form to GHC-SCW Care Management at (608) 831-6099

Failure to obtain Prior Authorization may result in GHC-SCW not providing coverage for the service. The prior authorization lists may differ depending on health plan type.

Which Prior Authorization Form To Use?

Medical Services Prior Authorization Forms

• ​Perinatology: Prior Authorization Form 
  
• Unattended Sleep Study (CPT Code 95806) 
• GHC-SCW Primary Insurer: Home Sleep Test and CPAP Auto Titration Order Form Please Fax to (608)222-2768
• Medicare Primary Insurer: Home Sleep Test Order Form Please Fax Form to (866) 215-7347
• PT/OT/SLT Therapy Requests: PT, OT and SLT Prior Authorization Form​
  
• All Other Medical Se​rvices: Prior Authorization Form
• Orthodontic Services: Submit the Prior Authorization Form together with Orthodontic Services Evaluation Form
  

Pharmacy and other Medication Requests ​

• Formulary Exception Request: M​edication Prior Authorization Request form. Please fax Medication Prior Authorization Requests to (608) 828-4810.
• Locating Medication Specific Forms: Visit https://www.navitus.com/. Select Prescribers and login using your NPI number and state of practice.
• Medical Specialty Injectable:  Medication Prior Authorization Request may be used when a drug- specific prior authorization form is not listed. Authorization Requests faxed to (608) 831-6099.
  

Behavioral Health and Substance Use Disorder Treatment Forms

• Request for Ongoing Behavioral Health Services form​
  
• Request for Substance Use Diso​rder Services form​
  

​ Questions

• Medication Related Questions & Requests: Contact the GHC-SCW Pharmacy department at (608) 828-4811.
• Coverage and Prior Authorization Requirements: Contact Member Services, Mon. - Fri., 8 a.m. - 5 p.m. at (608) 828-4853 or toll free at 800-605-4327, and ask to speak with Member Services.
• Prior Authorization Status: Contact GHC-SCW Care Management team by phone (608) 257-5294, or by fax (608) 831-6099.