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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

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: 800-856-9434
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 either the Inpatient Prior Authorization Form or Outpatient Prior Authorization Form to:

800-498-8217

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 our General Prior Authorization 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 OptumRx 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 CountyCare form: Medication Prior Authorization Request Form.
  2. Fax to OptumRx at 866-511-2202
  3. Once approved, OptumRx notifies the prescriber by fax.
  4. If the clinical information provided does not explain the reason for the requested prior authorization medication, OptumRx 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 OptumRx Pharmacy Help Desk at: 877-235-1981.
  6. All pharmacy prior authorization requests for CountyCare members should be submitted to OptumRx.

Specialty Pharmacy Services Prior Authorization

To submit a specialty pharmacy prior authorization, complete the appropriate drug-specific prior authorization form from the list below in the section.

For all else, complete and submit our General Prior Authorization Request Form.

Fax all completed forms to OptumRx at 866-511-2202

Certain medications are only covered when supplied by CountyCare’s preferred specialty pharmacy network. Providers can call 855-427-4682 to learn more. If approved, OptumRx will contact the provider or member for delivery confirmation.

Drug-specific Prior Authorization Forms


Dental Prior Authorization

To submit a dental prior authorization, Login Here

Or call 888-281-2076

Or fax our Prior Authorization Form to:
1-262-834-3589

Prior authorization requires Participating Providers to submit "documentation" associated with certain dental services for a Member. Participating Providers will not be paid if this "documentation" is not provided to DentaQuest. DentaQuest utilizes specific dental utilization criteria as well as an authorization process to manage utilization of services.


Vision Prior Authorization

To submit a vision prior authorization, Login Here

Or call 888-696-9551

Or fax our Prior Authorization Form to:
1-888-696-9552


Covered Services & Limitations


  

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