Medical Preauthorization Forms

If you're a contracted provider, please log in to your PEHP Provider Account to view and download authorization forms. Send all forms and applicaple patient notes to document clinical information. Fax the form back to the PEHP Case Management Department at 801-328-7449 or mail to: PEHP Case Management, 560 East 200 South Salt Lake City, UT 84102. If you have preauthorization questions, call PEHP at 801-366-7555.

Non-Contracted Provider? Request Preauthorization Form. Send us your contact information, fax number, and which form(s) you need. 

This list  shows medical codes with applicable policies that require preauthorization.

This list   shows some common services that require preauthorization. Genetic testing is commonly overlooked.