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USAble Mutual Insurance Company

Forms for Doctors & Hospitals

PRIOR AUTHORIZATION FOR REQUESTED SERVICES

The medical necessity of certain services must be established through a prior or pre-authorization process before they can be performed. Please refer to AHIN or the member’s benefit certificate to determine which services need pre-authorization. Prior authorization requests will be reviewed by the Prior Authorization Team based on medical guidelines from USAble Mutual.

What to include with the completed Prior Authorization form [pdf, 80 KB]

  • Requested service(s)
  • Name and telephone number of contact person
  • Fax number to send determination
  • Requesting / Performing Provider’s NPI or Provider ID
  • Copy of member’s insurance card (front/back)
  • CPT Code(s) and/or HCPCS Code(s)
  • Medical records to support requested services