Prior Authorization Forms
Gundersen Health Plan utilizes and adopts nationally developed medical policies; commercially recognized criteria sets; regionally developed medical coverage policies; and locally produced specialty medical coverage policies. Additionally, the Health Plan involves appropriate practitioners in development, adoption and review of criteria and medical coverage policies. All criteria are available upon request by contacting the Health Plan Medical Management Department. A written copy can be sent electronically, by mail, or directly communicated via the telephone.
Commercial Prior Authorization
- Procedures and Services Requiring Prior Authorization (PA Grid)
- Gundersen Health Plan Commercial Prior Authorization /DME Request Form (must be completed when submitting a request)
- Gundersen Health Plan Commercial Referral Authorization
- Quartz General Prior Authorization Form
Pharmacy Forms for Healthcare Providers
If you have questions about the drug prior authorization process, please review the provider manual, or the drug prior authorization process overview.
- Employer Group or Individual Plan Drug Prior Authorization
- Request for Medicare Prescription Drug Coverage Determination Form
- Pharmacy and Therapeutic Committee: Formulary Request for Review
Provider Change Notification Form
Please use this form to notify Gundersen Health Plan of any changes, additions or terminations within your facility.
- New Practitioner Form
- Practitioner Termination Form
- Practitioner or Provider Change Form
- New Location Form
- Location Termination Form
Provider Participation Request Form
MyPlanTools Access Request Form