Effective October 28, 2020: New Prior Authorization Fax Numbers

Date: 08/11/20

Effective October 28, 2020, Superior HealthPlan will update certain prior authorization forms to reflect new fax numbers. The Behavioral Health Request/Medical Records fax number was updated for all products and the Standard Request fax number was updated for Ambetter from Superior HealthPlan.

To see new forms, please visit the links below:

• 2020 Inpatient Medicaid Authorization Form
• 2020 Outpatient Medicaid Authorization Form
• 2020 Inpatient Medicare Authorization Fax Form
• 2020 Inpatient Ambetter Prior Authorization Fax Form

Providers should continue utilizing current prior authorization forms until October 28, 2020. These forms can be found:

• On Superior’s Provider Forms webpage:
  • Under Medicaid Prior Authorization Forms
    • 2020 Inpatient Medicaid Authorization Form (PDF)
    • 2020 Outpatient Medicaid Authorization Form (PDF)
  • Under Medicare Acute Care Services
    • 2020 Inpatient Medicare Authorization Fax Form (PDF)
• On Ambetter’s Provider Forms webpage:
  • Under Behavioral Health
    • 2020 Inpatient Prior Authorization Fax Form (PDF)

For questions, please contact Provider Services at:

• 1-877-687-1196 (Ambetter from Superior HealthPlan)
• 1-877-391-5921 (Medicaid [STAR, STAR Health, STAR Kids, STAR+PLUS], CHIP, STAR+PLUS Medicare Medicaid Plan (MMP) and Allwell from Superior HealthPlan [HMO, HMO SNP])