Forms

Prior authorizations and other forms.

Prior Authorization (PA) DATE ADDED
Universal Prior Authorization (PA) Form - All Drugs 09/03/2021

Fax Prior Authorizations

Please fax prior authorization requests to the following number:

Prior Authorization Fax Line
(858) 357-2612

Telephonic Prior Authorizations or Inquiries

For telephonic prior authorization requests or inquiries regarding a prior authorization call: 

Clinical Call Center
(844) 336-2676
(8:00 AM - 7:00 PM EST / 7 days per week)

Denials and Appeals

  • A member or an authorized representative may appeal a prior authorization denial.
  • The provider may also submit an appeal. If the appeal is on behalf of the member, the provider will require the member's consent.
  • Written appeals must be submitted within thirty (30) days of receipt of the denial letter.

Send appeals to the address below:

Attention: Appeals and Grievances Department
MedImpact Healthcare Systems, Inc.
10181 Scripps Gateway Court
San Diego, CA 92131

Or fax:
(858) 790-6060