Provider Forms

Our new Utilization Management (UM) partner offers different forms for each type of Prior Authorization you may request in order to get the most specific and efficient information. If your patient’s service is not listed, you may use the General Medical Prior Authorization Form listed below.

• Abdominoplasty
• Autologous Cultured Chondrocytes
• Breast Reconstruction
• Eyelid and Brow Repair (Blepharoplasty)
• Genetic testing
• Infuse Bone Graft
• Panniculectomy
• Pharmaceuticals Unclassified Medical Benefit Drug
• Port Wine Stain – Abnormal Vascular Lesion Treatment
• Reduction Mammoplasty
• Rhinoplasty
• Septoplasty
• Skin substitute
• Spinal Cord Stimulator
• Transgender Services
• Vagus Nerve Stimulation
• General Medical Prior Authorization 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 .

• Click here to access Optum Rx’s specific drug forms.
• Short Acting Opioid – Prior Authorization Form 

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. 

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.

• EPO Referral Form

Please note, referrals are only considered in rare circumstances and are generally NOT necessary for the following services:

• Emergency Care
• Urgent Care
• Maternity care for new members in 3rd trimester of pregnancy (prior authorization is required)
• Full-time students enrolled in Institutes of Higher Learning seeking behavioral health or substance abuse disorder treatment outside of CGHC’s services area but within the state of Wisconsin.

* Please note follow-up care is not covered at out-of-network facilities.

• Claim Reconsideration Form
• Network Participation Request Form (fillable pdf)
• NSA Open Negotiation Request 
• Open Negotiation Request Instructions
• Provider Change Form (pdf)
• Provider Change Form (fillable pdf)
• Provider Contact Form (fillable pdf)
• Provider EFT Form