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The form collects patient demographics and insured ID, requesting provider details, place of service information, and service specifics including DOS, diagnosis codes, CPT/HCPCS codes with units, and DME rental or purchase selections. Submit supporting clinical documentation such as medical records, x-ray reports, lab results, plan of care, and letters of medical necessity, and send the completed form via secure email, fax, or mail to OptumCare.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/optumcare-prior-authorization-form/283989/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/optumcare-prior-authorization-form/283989.png","ImageObject",442,249,{"name":88,"@type":89},"Jiven","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-30","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":35},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"How should providers submit OptumCare prior authorization requests?","Question",{"text":108,"@type":109},"Providers may submit through a secure system via secure email, request secure email submission through the service center if they do not have secure email, fax to the provided fax number, or mail the completed form to OptumCare.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Which request categories can be selected on the form?",{"text":113,"@type":109},"The form asks the submitter to mark one option: ROUTINE, DATE SENSITIVE, or URGENT, based on how soon the service date is and the member’s health impact if not completed within 72 hours.",{"name":115,"@type":106,"acceptedAnswer":116},"What supporting clinical information must be included with the request?",{"text":117,"@type":109},"The request should include all clinical information supportive of the requested procedure(s), including x-ray reports and diagnostic test results, plus attachments such as plan of care, medical records, lab reports, letter of medical necessity, and progress notes.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},283989,1790012997,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":35,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},1099513958607,"https://ap-avatar.wpscdn.com/avatar/100002390cf8733938c?x-image-process=image/resize,m_fixed,w_180,h_180&k=1778829742770036399","Instructions:  \n• Please complete the form located on page two. Fields with an asterisk ( * ) are required.  \n• Please include all clinical information, x-ray reports, and diagnostic test results supportive of the procedure(s) requested  \nYou now have several options for submitting your Prior Authorization requests to OptumCare:  \n• If you have your own secure system, please submit authorization  \nrequests to: [LCD_UM@optum.com](LCD_UM@optum.com)  \n• If you do not have a secure email in place, please contact our service center at 1-877-370-2845. We will ask for your email address and will send a secure email for Prior Authorization requests to be sent to our office.  \n• You can fax your requests to 1-888-992-2809  \n• Or mail the completed form to:  \nOptumCare  \nAttention: Prior Authorization  \nPO Box 46770  \nLas Vegas, NV 89114-6770  \n\n| PLEASE MARK ONE OF THE FOLLOWING:\u003Cbr>□ ROUTINE (Normal, non-urgent request)\u003Cbr>□ DATE SENSITIVE (Date Sensitive is defined as an upcoming date of service)\u003Cbr>□ URGENT (Urgent is defined as significant impact to health of the member if not completed within 72 hours) |  |\n| --- | --- |\n| PATIENT INFORMATION:\u003Cbr>LAST NAME:   FIRST NAME:   DOB:   PHONE:   INSURED ID:  \u003Cbr>ADDRESS:   CITY:  STATE: ZIP:   |  |\n| REQUESTING PROVIDER INFORMATION:\u003Cbr>PROVIDER NAME:  GROUP NAME:  SPECIALTY:  TAX ID \\#:  ADDRESS:  CITY:  STATE:  ZIP: \u003Cbr>CONTACT NAME:  PHONE:   EXT:  FAX:  | PLACE OF SERVICE INFORMATION:\u003Cbr>PROVIDER/FACILITY:  GROUP NAME:  SPECIALTY:  TAX ID \\#:  ADDRESS:  CITY:  STATE:  ZIP: \u003Cbr>CONTACT NAME:  PHONE:   EXT:  FAX:  |\n| SERVICES: DOS:   DME ITEMS (CHECK ONE): □ RENTAL □ PURCHASE TYPE OF SERVICE: □ OUTPT □ INPT □ Office □ Surgery Ctr □ SNF □ Home □ Other: \u003Cbr>DIAGNOSIS CODE(S):               CPT/HCPCS CODE(S) (INCLUDE NUMBER OF UNITS PER CODE):      \u003Cbr>• PLEASE ATTACH SUPPORTING CLINICAL INFORMATION (E. G. , PLAN OF CARE, MEDICAL RECORDS, LAB REPORTS, LETTER OF MEDICAL NECESSITY, PROGRESS NOTES, ETC.) |  |\n| • ALL SECTIONS OF THIS FORM MUST BE COMPLETED.\u003Cbr>• ON ADVERSE DETERMINATIONS, A RECONSIDERATION/EXPEDITED APPEAL MAY BE REQUESTED.\u003Cbr>This referral/authorization is not a guarantee of payment. Payment is contingent upon eligibility, benefits available at the time the service is rendered, contractual terms, limitations, exclusions, and coordination of benefits, and other terms & conditions set forth in the member’s Evidence of Coverage.\u003Cbr>The information contained in this form, including attachments, is privileged and confidential & is only for the use of the individual or entities named on this form. If the reader of this form is not the intended recipient or the employee or the agent responsible to deliver to the intended recipient, the reader is hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If this communication has been received in error, the reader shall notify sender immediately and shall destroy all information received. |  |","cbCaidyvp6f6XAa7","https://ap.wps.com/l/cbCaidyvp6f6XAa7","pdf",142867,"English","# Submission Instructions\n## How to Mark Request Type\n# Required Form Information\n## Patient Information\n## Requesting Provider Information\n## Place of Service Information\n## Services and Codes\n# Documentation and Submission Notes","[{\"question\":\"How should providers submit OptumCare prior authorization requests?\",\"answer\":\"Providers may submit through a secure system via secure email, request secure email submission through the service center if they do not have secure email, fax to the provided fax number, or mail the completed form to OptumCare.\"},{\"question\":\"Which request categories can be selected on the form?\",\"answer\":\"The form asks the submitter to mark one option: ROUTINE, DATE SENSITIVE, or URGENT, based on how soon the service date is and the member’s health impact if not completed within 72 hours.\"},{\"question\":\"What supporting clinical information must be included with the request?\",\"answer\":\"The request should include all clinical information supportive of the requested procedure(s), including x-ray reports and diagnostic test results, plus attachments such as plan of care, medical records, lab reports, letter of medical necessity, and progress notes.\"}]","OptumCare Prior Authorization Form | PDF",1789624012]