For dates of submission on or after 12/01/2024, please use the new CGHC Provider Portal to submit medical prior authorizations: https://providerportal.caresource.com/WI
To fax in a medical authorization, please and use this form
Please submit Drug Specific forms when applicable to avoid delayed or denied authorization requests.
Please submit completed prescription authorization requests via phone by calling 1.800.711.4555, electronically through go.covermymeds.com/OptumRx .
If you cannot find the prior authorization form you are looking for by visiting OptumRx’s website, please complete the general prescriptions form here.
NOTE: When submitting an authorization request, it is important to use Drug Specific forms when applicable. Please use the most up-to-date forms on OptumRx’s website and be sure to include all of the relevant information. If a submitted request is missing information the request(s) can be delayed or denied due to lack of information. Please check for the drug specific form because the use of out dated or general forms may not contain all required elements and could result in a delay or denial of the authorization request.
CGHC will require prior authorization for ALL out-of-network services except in limited circumstances (such as Emergent/Urgent care). Please see our updated provider manual for additional detail.
If there are not any in-network providers that can provide a medically necessary service, in-network providers may submit a written referral for a member to see an out-of-network provider. The referral request will be reviewed by CGHC.
Please note, referrals are only considered in rare circumstances and are generally NOT necessary for the following services:
* Please note follow-up care is not covered at out-of-network facilities.
