CountyCare - Prior Authorizations

CALL US 312-864-8200

Effective March 1, 2018, CountyCare is requiring the use of updated Prior Authorization forms for Medical Inpatient, Medical Outpatient, and Behavioral Health Services. New Prior Authorization Forms for Medical and Behavioral Health Services were re-designed to help CountyCare and our providers more effectively and efficiently process prior authorization requests. Previous versions of these forms will no longer be accepted after March 31, 2018.  Authorization requests submitted on the old forms will be rejected and returned.

Prior Authorizations

Medical Services Prior Authorizations

For faster turn-around-time and easier tracking- submit your Medical Prior Authorization request via the CountyCare Provider Portal! Click here to Login or find out more information

Call 312-864-8200 711 TTD/TTY Option 4

Or fax either the Inpatient Prior Authorization Form or Outpatient Prior Authorization Form to the following numbers:

Inpatient Medical Prior Authorization Form: 1-800-856-9434 
Outpatient Medical Prior Authorization Form: 1-866-209-3703

Please note: effective 10/1/2017, CountyCare began requiring submission of HFS-Required forms to UM with the prior authorization request for appropriate DME services. Please find the forms on our website at  After March 31, 2018, DME authorization requests missing the appropriate HFS required form will be rejected and returned to the provider.

Some services require prior authorization from CountyCare in order for reimbursement to be issued to the provider. CountyCare has a list available for providers that includes all services requiring prior authorization. All out-of-network services require prior authorization, with the exception of Emergency Care and Family Planning Services.

Prior authorization should be requested at least seven (7) calendar days before the requested service delivery date. The provider and member will be notified of the decision for inpatient services or urgent/expedited outpatient services within one business day of the determination. The provider and member will be notified of the decision within three business days of the determination for routine outpatient services. For more information on prior authorization timelines and processes, see the CountyCare Provider Manual.

To verify whether prior authorization is necessary or to obtain prior authorization for a specific service, call:

CountyCare Medical Management/Authorization Department
Telephone 312-864-8200 / 855-444-1661
Inpatient Fax: 866-209-3703
Outpatient Fax: 866-209-3703

For durable medical equipment that requires a prior authorization, in addition to completing our standard prior authorization form, an appropriate State of Illinois DME form must also be provided.

Behavioral Health Services Prior Authorizations

For faster turn-around-time and easier tracking- submit your Medical Prior Authorization request via the CountyCare Provider Portal! Click here to Login or find out more information

Call 312-864-8200 711 TTD/TTY Option 4

Or fax this BH Authorization Form to:


This form includes symptom check boxes to help guide providers on required clinical documentation. In addition, the form asks for key contacts to help Utilization Management coordinate transition of care and care management in a timely manner.

For each of the services listed below, providers should seek a prior authorization from CountyCare’s Utilization Management Department by calling 312-864-8200, 8:30 a.m. – 8:00 p.m. Central, Monday-Friday.

Behavioral health services including:

  • Inpatient Psychiatric
  • Partial Hospitalization
  • Intensive Outpatient Therapy
  • Psychological Testing
  • Neuropsychological Testing
  • Electroconvulsive Therapy (ECT) ▪ Substance Use Disorder Treatment/Rehabilitation

Community support services/behavioral health including:

  • Psychological Testing
  • Community Support: Prior Authorization required after 200 units
  • Case Management: Prior Authorization required after 200 units.
  • Psychological Rehabilitation: Prior Authorization required after 800 units.

Illinois Division of Alcohol and Substance Abuse Services (DASA):

  • DASA Services DO NOT require Prior Authorization.

Outpatient behavioral health therapy services, for mental health and substance use, do not require Prior Authorization.

Prescription Drug Services Prior Authorizations

To submit a prescription drug service prior authorization, complete and submit the Medication Request Form

Due to the high cost of some prescription drugs, CountyCare maintains a Preferred Drug List (PDL) and requires prior authorization for certain prescription drugs. The CountyCare PDL includes a broad spectrum of generic and brand name drugs. Clinicians are encouraged to prescribe from the CountyCare PDL for their patients who are members of CountyCare.

CountyCare works with MedImpact to administer pharmacy benefits, including the pharmacy prior authorization process. CountyCare requires prior authorization for select drugs on the PDL as well as ALL drugs not on the PDL. Most specialty drugs are not on the PDL and require prior authorization as described below.

Follow these steps for efficient processing of your pharmacy prior authorization requests:

  1. Complete the MedImpact form: Medication Request Form.
  2. Fax to MedImpact at 858-790-7100
  3. Once approved, MedImpact notifies the prescriber by fax.
  4. If the clinical information provided does not explain the reason for the requested prior authorization medication, MedImpact responds to the prescriber by fax, offering PDL alternatives.
  5. For urgent or after-hours requests, a pharmacy can provide up to a 72-hour supply of most medications by calling the MedImpact Pharmacy Help Desk at: 888-402-1982.
  6. All pharmacy prior authorization requests for CountyCare members should be submitted to MedImpact.

Specialty Pharmacy Services Prior Authorization

To submit a specialty pharmacy prior authorization, complete the Medication Request Form.

Fax all completed forms to MedImpact at 858-790-7100.

Dental Prior Authorization

To submit a dental prior authorization, Login Here

Or call 866-337-1594

Vision Prior Authorization

To submit a vision prior authorization, Login Here

Or call 866-337-1596

Covered Services & Limitations