Forms and resources for health care professionals
Diabetes management (DM) process
This document describes the process for providing diabetes disease management program services to members.
Patient consent and assignment of benefits (AOB)
Please complete and return the form to the requesting department.
Multiple sclerosis referral form
Optum specialty referral form for multiple sclerosis. Send us the form and we will take care of the rest.
Oncology referral form
Optum specialty referral form for oncology. Send us the form and we will take care of the rest.
Electronic remittance and appeal rights for UHC CT
Learn about contracted provider reconsiderations and more.
Forum for evidence-based medicine: COVID-19 issues
Sign up for educational information about COVID-19.
Optum Care Case Management
Our case management programs help reduce health care spend and keep our most vulnerable members safe.
Benzodiazpines Prior Authorization Form
This is a Medicare form for benzodiazepines prior authorization requests.
Opioids & Medication Limits Prior Authorization Request Form
Please use this form for all opioid requests including MME exceeded, concurrent uses, quantity limits.
Immune globulin therapy enrollment form
Optum specialty referral/enrollment form for immune globulin. Send us the form and we will take care of the rest.
Authorization to use and disclose protected health information
Please complete and return the form to the requesting department.
Request for access to protected health information
"Complete and return this form if you would like to access and inspect the information Optum Specialty Pharmacy maintains and uses to make decisions about the services we provide you. "
Optum Care ACE Smart Edits
Learn more about the Advanced Communication Engine and the edits currently in place.
Immunoglobulin referral form
Optum Infusion Pharmacy IVIG and SCIG referral/enrollment form. Send us the referral and we will take care of the rest.
Claims provider manual
Our provider claims guide offers our network providers key information and support in submitting claims.
COVID-19 member direct mail letter #1
Letter sent to all Optum Care–Arizona members about COVID-19 important updates.
State of Arizona prior authorization form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Texas Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Electronic remittance and appeal rights - Humana MA
Learn about Provider Appeals for NY members.
Partial Copay Waiver (PCW) Exception Prior Authorization Request Form
This is for CalPERS Plan only.
Utah COVID-19 Health Plan Provisions
The latest UnitedHealthcare COVID-19 related resources.
Electronic remittance and appeal rights for Emblem CT
Learn about contracted provider reconsiderations and more.
Electronic remittance and appeal rights - Premera MA
Learn about Provider Appeals for WA members.
Prior authorization request form
View the prior authorization request form for the Indiana, New York and Ohio markets.
Massachusetts Prior General Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Colorado Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Florida Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Arizona Chemotherapy Drug Prior Authorization
Learn more about the prior authorization process.
Medical coverage decision criteria
See criteria by plan to help determine coverage eligibility.
Prior authorization grid
View a list of CPT codes requiring prior authorization for Idaho
Direct admit to SNF form
Complete this form to initiate an admission to a skilled nursing facility (SNF).
Alpha-1 referral form
Optum Infusion Pharmacy referral/enrollment form for alpha-1 proteinase inhibitor therapy
Healthcare Reform Copay Waiver Request Form
This for is for UnitedHealthcare (non-Medicare).
Healthcare effectiveness data and information
Use this reference guide to learn how we measure performance.
New Mexico Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Medicare Part D Prior Authorization for Hospice Form
Use this form for hospice enrollees.
Step therapy prior authorization requirements
Get prior authorization requirements and instructions.
COVID-19 and health plan provisions in Connecticut
Get access to the latest plan information and COVID-19 resources.
Electronic remittance and appeal rights - UHC ACO REACH
Find information on contracted provider reconsiderations.
Home Health Care prior authorization intake request form
View the prior authorization request form for the Connecticut, Indiana, and Ohio market.
Electronic remittance and appeal rights - Humana MA
Learn about Provider Appeals for WA members.
Connecticut Prior Authorization Alert (OCN)
Reference for obtaining Prior Authorization lists and guidelines.
Neuromuscular disorder referral form – migraine, cervical dystonia, overactive bladder
Optum specialty referral form. Send us the form and we will take care of the rest.
Provider quick reference guide
Get important details for the Arizona market in Maricopa and Pinal County.
Prior authorization request form
Use this form to request prior authorization of necessary services in Oregon. See the prior authorization grid for a list of this year's services.
Hepatitis C referral form
Optum specialty referral form for hepatitis C patients. Send us the form and we will take care of the rest.
Pre-service peer-to-peer requests
Find guidelines for requesting a peer-to-peer discussion.
Optum Clinical Claims Review (CCR) Pre-Pay Review Quick Reference Guide
Learn about the CCR pre-pay review process
Unbranded IV anti-infectives referral form
Unbranded antibiotic infusion referral/enrollment form
Medical Management Reference Guide
View the Optum Care–Arizona medical management/clinical reference guide.
Utah Oncology Authorization Request Form
Treatment request form for medicine used for chemotherapy.
Unbranded immunoglobulin referral form
Unbranded IVIG and SCIG infusion referral/enrollment form
Kansas City Home Health Prior Authorization FAQ
Get important details about prior authorizations for home health services
Unbranded alpha-1 referral form
Unbranded referral/enrollment form for alpha-1 proteinase inhibitor therapy
Optum Care ACE quick reference guide
Get important details about the Advanced Communication System.
Case Management Form and Guide
Use our form and guide for the Optum Care patient referral programs.
Vendor partner resources
Find more details about three of our vendor partners; Wound tech, Dispatch Health and Arizona Palliative Home Care.
Massachusetts Chemotherapy and Supportive Care PA Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Prior authorization supporting documentation cover sheet
View the supporting documents (medical records) cover page for New Mexico
Request to amend protected health information
Please complete and return the form to the requesting department.
Michigan Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Electronic remittance and appeal rights - Elevance MA (Anthem)
Learn about Provider Appeals for NV members.
Electronic remittance and appeal rights - UHC MA
Learn about Provider Appeals for AZ, UT, NV, CO, NM ID, KS, MO members.
Prior authorization request form
Use this form to request prior authorization of necessary services in Washington. See the prior authorization grid for a list of this year's services.
Cozeva resource guide
If you need help with coding in Cozeva, check out this helpful guide.
Standard personal health information (PHI) authorization form
Complete and return this form to give your permission to discuss and/or release your PHI to a person who is your Authorized Representative.
Case Management Provider Follow-up Form
This form provides updates on program progress and request collaboration.
Biologics infusion referral form
Optum Infusion Pharmacy referral/enrollment form chronic inflammatory disorders such as Crohn's disease, ulcerative colitis, and rheumatoid arthritis. Send us the referral and we will take care of the rest.
Provider administrative guide
This guide identifies the tools and support services available to Optum Care–Kansas City providers.
Unbranded hemophilia and bleeding disorders referral form
Unbranded hemophilia referral/enrollment form
Utilization management program description
This document describes the program and how it works.
Provider referral form for program
Use this form to request programs for your patient to be enrolled in at Optum.
Request for access to protected health information
Please complete and return the form to the requesting department.
Skilled Nursing Notice – Medicare Non-Coverage
Notify patients of the effective date coverage of their current Skilled Nursing Services will end.
Illinois Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Prior authorization request form
Use this form to request prior authorization of necessary services in New Mexico. See the prior authorization grid for a list of this year's services.
Home Health Notice – Medicare Non-Coverage
Notify patients of the effective date coverage of their current Home Health Services will end.
Washington non-PCP quick reference guide
This guide provides information about prior authorizations and referrals, submitting claims, customer service and more.
Curo quick start guide provider authorization module
The Curo provider module quick start guide serves as a high-level overview of the benefits and basic functionality of the platform.
Inter-rater reliability
This document covers how to do annual IRR training for prior authorization clinical staff.
Pulmonary arterial hypertension referral form
Optum specialty referral form for pulmonary arterial hypertension (PAH). Send us the form and we will take care of the rest.
Request for confidential communications at an alternative address
Please complete and return the form to the requesting department.
Optum-WA physician/provider change form
Please use this form to request demographic updates, remit address changes, or updates to your practice information.
Prior authorization supporting documentation cover sheet
View the supporting documents (medical records) cover page for Connecticut
Medicare Advantage home health prior authorization update (APN)
See updated guidelines for home health services
Primary care provider referral forms
View primary care provider referral forms for Colorado.
Home Health Prior Authorization FAQ
Get important details about prior authorizations for home health services.
Washington Provider Manual Medicare
Our provider guide offers our network providers key information and support to provide effective care in the Washington market.
Contracted provider appeal for medical necessity
Complete this form for a medical necessity appeal.
Request to amend protected health information (PHI)
Please complete and return the form to the requesting department.
New Hampshire Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Connecticut Prior Authorization Alert (APN)
Reference for obtaining Prior Authorization lists and guidelines.
Optum.com navigation
Learn how to navigate Optum.com; signing in and accessing resources.
Attestation measures guide
Use this guide as a resource to complete quality attestation forms.
Prior authorization supporting documentation cover sheet
View the supporting documents (medical records) cover page for Indiana, Ohio, and New York
Utilization decision criteria
Optum uses decision-making criteria that are objective, measurable and evidence based.
Provider referral form for program
Use this form to request programs for your patient to be enrolled in at Optum.
OCKC Admission Notification Requirements
Learn more about admitting patients in Kansas and Missouri.
Request for record of non-routine disclosures of protected health information
Please complete and return the form to the requesting department.
Provider dispute resolution forms
Use these forms when working with patients in Colorado.
Prior authorization supporting documentation cover sheet
View the supporting documents (medical records) cover page for Washington
In-network skilled nursing facilities
This list provides an overview of the current in network Skilled Nursing Facilities and Home Health Agencies in Optum Care Network–Idaho.
Clinical Diabetes Management program referral
Learn more about the Optum Clinical Diabetes Management program in Arizona.
Notice of privacy practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Provider dispute resolution form - CT
Challenge, appeal or request reconsideration of a claim.
Care transition procedures
This document defines the process for discharging and safely transitioning Medicare Advantage patients from an inpatient facility.
Quality Measures At-A-Glance
Measures, descriptions, documenting tips and coding for quality measures.
Medicare Advantage home health prior authorization update
See updated guidelines for home health services.
Appendix to Provider Administrative Manual
Use this appendix in Optum Care Network – Colorado
Curo training guide provider authorization module
An in-depth process outline for the Optum provider authorization module.
Provider dispute resolution form
Challenge, appeal or request reconsideration of a claim.
Washington Provider Manual Medicaid
Our provider guide offers our network providers key information and support to provide effective care in the Washington market.
Osteoarthritis referral form
Optum specialty referral form. Send us the form and we will take care of the rest.
Notice of privacy practices
Please complete and return the form to the requesting department.
Hemophilia and bleeding disorders referral form
Optum Infusion Pharmacy referral/enrollment form for hemophilia and bleeding disorders. Send us the referral and we will take care of the rest.
Oncology REMS referral form
Optum specialty referral form for REMS oncology medications. Send us the form and we will take care of the rest.
IV anti-infectives referral form
Optum Infusion Pharmacy referral/enrollment form for antibiotics. Send us the referral and we will take care of the rest.
Massachusetts Hepatitis-C Medications Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Opioids & Medication Limits Prior Authorization Request Form-UnitedHealthcare Medicare only
Please use this form for all opioid requests including MME exceeded, concurrent uses, quantity limits.
Provider administrative manual
See our Provider Administration Manual for key information and support in providing effective care for Colorado.
Electronic remittance and appeal rights
Learn about contracted provider reconsiderations and more.
Request for confidential Optum Infusion Pharmacy communications at an alternative address or by another means
Please complete and return the form to the requesting department.
Medical management quick reference guide
Get important details for the Optum Care medical management programs.
Neuromuscular disorder referral form
Optum specialty referral form for neuromuscular disorders. Send us the form and we will take care of the rest.
Electronic remittance and appeal rights - Humana MA
Learn about Provider Appeals for CO, NV, NM members.
Electronic remittance and appeal rights - UHC MA
Learn about Provider Appeals for WA members.
Home parenteral nutrition referral form
Optum Infusion Pharmacy referral/enrollment form for parenteral nutrition. Send us the referral and we will take care of the rest.
Medical management quick reference guide
Get important details for the Optum Care medical management programs.
Dermatology referral form
Optum specialty referral form for Dermatology. Send us the form and we will take care of the rest.
Diagnosis attestation form quick guide
This attestation form lists the diagnosis/conditions previously reported for a patient or conditions thought to be correct.
State of California prior authorization form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Advance beneficiary notice of noncoverage (ABN)
Please complete and return the form to the requesting department.
2023 HEDIS Measure CPT Category II Codes
Utilizing CPT Category II codes provides more complete information to the plan and much more.
Important claims submission information
Learn about the preferred method of claims submissions.
New hope for neurological conditions
Learn how a holistic model enhances multiple sclerosis care.
Prior authorization grid
View a list of CPT codes requiring prior authorization for Kansas City
Home Health Notice – Medicare Non-Coverage
Notify patients of the effective date coverage of their current Home Health Services will end.
Prior authorization request form
Use this form to request prior authorization of necessary services in Connecticut. See the prior authorization grid for a list of this year's services.
Fertility general referral form
Optum specialty fertility referral form. Send us the form and we will take care of the rest.
Electronic remittance advice (ERA) form
Find helpful documents to complete your ERA application.
Electronic funds transfer
Learn more about enrolling in EFT and electronic remittance advice (ERA) enrollment.
Cultivating community through COVID-19
Learn how we're creating a sense of community and well-being during COVID-19.
Medical management program referral guide and form
Refer a patient for one of our medical management programs.
Advance beneficiary notice of noncoverage (ABN)
Please complete and return the form to the requesting department.
Medicare Advantage home health prior authorization update (OCN)
See updated guidelines for home health services
EDI Companion Guide
HIPAA Companion Guides describe Optum Rx specific technical details for EDI transactions.
Laboratory Protocol in Arizona
Use this referral policy for services in Optum Care–Arizona.
Request to restrict use and disclosure of protected health information
Please complete and return the form to the requesting department.
Prior authorization grid
View a list of CPT codes requiring a prior authorization for Indiana, Ohio and New York.
Unbranded parenteral nutrition referral form
Unbranded parenteral nutrition infusion referral/enrollment form
Prior authorization online submission – tips and tricks
This is a reference for an online submission.
Optum Prepayment Review System quick reference guide
Learn more about the Optum Prepayment Review System.
Member satisfaction survey process
Learn the steps to evaluate members' satisfaction and complaints.
Oregon Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Optum Provider Change Form
Please use this form to request demographic updates, remit address changes, or updates to your practice information.
UHC West of California delegated medical group auto-authorization form
This form for UnitedHealthcare (non-Medicare).
Appeal information request policy
This policy outlines the process for sending denial documents to the health plan or QIO for appeal consideration.
General referral form
General Optum specialty referral form. Send us the form and we will take care of the rest.
Massachusetts Synagis Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Skilled nursing facilities manual
Get important details for skilled nursing facilitates (SNFs).
Skilled Nursing Notice – Medicare Non-Coverage
Notify patients of the effective date coverage of their current Skilled Nursing Services will end.
Optum Care Kansas City Case Management Overview
Use this guide to learn more about Kansas City Case Management.
Electronic remittance and appeal rights - UHC MA
Learn about Provider Appeals for IN, NY, OH members.
Gastroenterology referral form
Optum specialty referral form. Send us the form and we will take care of the rest.
Clinical programs quick reference guide
Get details about the clinical programs available in Optum Care Network–Idaho.
Minnesota Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Nevada Home Health Prior Authorization FAQ
Get important details about prior authorizations for home health services
Arizona Urgent Care Directory
Find Arizona urgent care locations and contact information.
Prior authorization supporting documentation cover sheet
View the supporting documents (medical records) cover page for Oregon
Medication Assistance Program
Download the Medication Assistance Program application for your Optum Care patients
Request for record of non-routine disclosures of protected health information
Please complete and return the form to the requesting department.
Provider dispute resolution form - APN
Challenge, appeal or request reconsideration of a claim.
Sublocade standard referral form
Optum specialty referral form. Send us the form and we will take care of the rest.
Osteoporosis referral form
Optum specialty referral form. Send us the form and we will take care of the rest.
Complex case management (CCM) process
This document outlines the steps involved in identifying, educating and helping these patients.
Compliance prior authorization and claims
Learn more about the correct coding for claims submissions.
Request to restrict use and disclosure of protected health information
Please complete and return the form to the requesting department.
Provider quick reference guide
This guide provides a glance at the most important details you'll need when working with Optum Care Network—Idaho patients.
Rheumatology referral form
Optum specialty referral form for Rheumatology. Send us the form and we will take care of the rest.
UnitedHealthcare MA plan coverage summaries
See coverage summaries and get the latest provider news.
Patient program referral form
Get important details for the Optum Care patient referral programs.
Louisiana Prior Authorization Form
This form for Optum Rx (non-Medicare) and UnitedHealthcare (non-Medicare).
Third party/donor referral form
Optum specialty referral form for donors and third party fertility patients.
Prior authorization supporting documentation cover sheet
View the supporting documents (medical records) cover page for Arizona, Colorado, Idaho, Kansas City, Nevada, and Utah
Nevada COVID-19 Health Plan Provisions
Information and resources on the changing federal and state regulatory health plan requirements related to COVID-19 in Nevada.
Clinical programs quick reference guide
Get details about the clinical programs available in Optum Care Network-Utah
Neuromuscular disorder referral form– achalasia, chronic anal fissure, fetrusor overactivity, spasticity, bleopharospasm
Optum specialty referral form. Send us the form and we will take care of the rest.
Provider-member program awareness
This document specifies how providers and members are made aware of Optum Care–Kansas City case and disease management programs and services.
Important update on SNF and LTACH prior authorization
See the updates to prior authorization requirements.
Prior authorization grid
View a list of CPT codes requiring prior authorization for New Mexico
Submitting an electronic prior authorization (e-PA)
Provider administrative manual
This manual provides detailed provider information for New York.
Top