Pre-Authorization Request

Pre-Authorization Request

Use this form to prepare a pre-authorization request before a planned medical service or procedure.

Disclaimer: Approval of this request does not guarantee payment. Sharing will only be considered up to the eligible maximum allowed amount based on the procedure codes and estimated cost listed on the submitted pre-authorization request, in accordance with program guidelines and member eligibility.

Questions? Call (866) 638-9355 or email preauth@netwell.com.