September 17, 2024
What is a PA Supplemental Form
An optional page meant to be used in conjunction with the plan’s Prior Authorization Request form when a request exceeds more than four (4) Procedure Codes. This page should never be submitted alone.
When to use the Supplemental Form?
When requesting more than four (4) Procedure Codes.
Are you required to include the PA Supplemental Form when submitting all requests?
No, it is an optional page. If your request doesn’t exceed four (4) procedure codes this page is not necessary or required
Where can I find a PA Supplemental Form?
The supplemental page is located on the plan site under “For Providers”.
