The CarePlus prior authorization form is a cover sheet that routes a provider’s request for coverage of a medical service or prescription drug to the CarePlus Health Services Department for clinical review. You download the correct version from the CarePlus provider site (or submit a Part D request through CoverMyMeds), fill in member, provider, and clinical fields that match the patient’s insurance card and chart exactly, attach supporting records, and send it in by portal, fax, or phone. Get the member ID, diagnosis codes, and clinical documentation right the first time and approval is usually quick; miss on any of them and the request cycles through rejections and resubmissions.
Where to Get the Right Form
CarePlus publishes separate forms for medical services and prescription drugs. The health services prior authorization form is a PDF on the CarePlus provider documents page and can be downloaded directly.1CarePlus Health Plans. Provider Documents and Forms
For Part D drug coverage requests, CarePlus partners with CoverMyMeds, which lets prescribers submit and track prior authorizations online with real-time determinations.2CarePlus Health Plans. Prior Authorization for Parts B and D If you’d rather work from a paper form, call 866-315-7587 to request a coverage determination form built for the specific drug. The standard CMS Coverage Determination Request Form is also accepted when a universal template is easier.
Completing the Form Without Triggering a Denial
The form collects three groups of information: member details, provider details, and the clinical request. An error in any one of them can stall the review, so cross-reference each field against the patient’s insurance card and medical record before you submit.
Member and Provider Fields
Enter the member identification number exactly as printed on the CarePlus insurance card. A single transposed digit sends the request into a dead end. The requesting provider must include their ten-digit National Provider Identifier, the standard numeric identifier required for all HIPAA transactions.3Centers for Medicare & Medicaid Services. National Provider Identifier Standard Add the facility’s tax identification number and a working phone number for the office so reviewers can reach you if they need more records or a clarification.
Clinical Fields
This is where most requests succeed or fail. The form requires ICD-10 diagnosis codes that reflect the patient’s current condition, along with the HCPCS or CPT procedure codes for the service being requested. For a drug request, document the exact medication name, dosage, strength, frequency, and expected duration of therapy. Vague or mismatched codes are the single fastest route to a denial. If the diagnosis code doesn’t logically connect to the procedure or drug being requested, the medical reviewer has no basis to approve it.
What to Attach
The form itself is only the cover sheet. What actually persuades the plan’s medical directors is the clinical evidence stapled to it. Include recent office visit notes that describe symptoms and treatment history, relevant lab results, and any imaging reports that support the need for the requested service or medication.
When the request involves a drug or procedure that isn’t first-line treatment, a clinical narrative explaining why standard alternatives were tried and failed, or why they’re medically inappropriate for this patient, carries significant weight. For step therapy situations, where the plan requires trying a lower-cost medication first, documentation of prior medication trials is essential. List each drug name, the dates of use, the dosage, and the specific reason the alternative was inadequate, whether that was side effects, lack of effectiveness, or a contraindication.
How to Submit the Form
CarePlus accepts prior authorization requests through several channels, and the right one depends on whether you’re asking about a medical service or a prescription drug.
Medical Services (Part C)
The preferred electronic route is the Availity Essentials portal, which allows real-time submission and status tracking.4CarePlus Health Plans. Prior Authorization Submissions Providers who aren’t yet registered with Availity can download the registration guide from the CarePlus provider site. You can also fax the completed form and supporting documents to CarePlus Health Services, or call the Health Services Department at 866-220-5448, Monday through Friday, 8 a.m. to 5 p.m. Eastern.5CarePlus Health Plans. Provider Prior Authorization List
Prescription Drugs (Part D)
Submit through CoverMyMeds for online tracking and real-time status updates. You can also fax the completed coverage determination form to CarePlus Clinical Pharmacy Review at 800-819-6204, or call 866-315-7587 Monday through Friday, 8 a.m. to 8 p.m. local time.2CarePlus Health Plans. Prior Authorization for Parts B and D
How Long CarePlus Has to Decide
Federal regulations set hard deadlines, and those deadlines got shorter in 2026. For a standard prior authorization request, CarePlus now has seven calendar days to issue a determination, down from the previous 14-day window. The change took effect January 1, 2026, under the CMS Interoperability and Prior Authorization Final Rule and applies to all Medicare Advantage organizations.6Centers for Medicare & Medicaid Services. CMS Interoperability and Prior Authorization Final Rule CMS-0057-F The 14-day timeframe still applies to organization determinations for services that don’t require prior authorization under the plan’s rules.7eCFR. 42 CFR 422.568 – Standard Timeframes and Notice Requirements for Organization Determinations
Expedited requests must be decided within 72 hours. These are reserved for situations where a standard-timeframe delay could seriously jeopardize the patient’s life, health, or ability to regain maximum function.8eCFR. 42 CFR 422.572 – Timeframes and Notice Requirements for Expedited Organization Determinations The plan can extend the 72-hour deadline by up to 14 calendar days only under narrow circumstances: the enrollee requests the extension, the plan needs medical evidence from an out-of-network provider that could change the outcome, or extraordinary circumstances justify the delay. If CarePlus extends the deadline, it must notify the enrollee in writing and explain the right to file an expedited grievance.
Once approved, the authorization notice includes a number that must appear on all related billing claims. Under current CMS rules the approval stays valid for as long as the treatment is medically necessary, with no arbitrary cutoff mid-treatment.9Premera Providers. New Medicare Advantage Prior Authorization Rules
If the Request Is Denied
CarePlus must send an Integrated Denial Notice (also called a Notice of Denial of Medical Coverage) that explains the specific reasons for the denial and outlines appeal rights.10Centers for Medicare & Medicaid Services. MA Denial Notice Read it carefully. The clock starts from the date printed on the notice.
Medical Service Appeals
You have 65 calendar days from the date on the denial notice to file. The member, an appointed representative, or the treating physician can submit the request. Include everything that would strengthen the case: additional medical records, a letter from the doctor explaining medical necessity, and any evidence that wasn’t part of the original submission. Fax appeals to 888-556-2128 or mail them to:11CarePlus Health Plans. Appeals
CarePlus Grievance and Appeals Dept.
P.O. Box 14165
Lexington, KY 40512-4165
If a standard timeline could seriously harm the patient, request an expedited appeal by phone through CarePlus Member Services at 800-794-5907. CarePlus must decide a standard reconsideration within 30 calendar days and an expedited reconsideration within 72 hours.12eCFR. 42 CFR 422.590 – Timeframes and Notice Requirements for Reconsiderations
Prescription Drug Appeals
Drug coverage denials follow a parallel track with the same 65-calendar-day filing window. Include the drug name, prescription number, reason for the appeal, and clinical rationale from the prescriber. Submit online through the CarePlus portal, by fax to 877-556-7005, by phone at 800-451-4651 (TTY: 711), or by mail to the same P.O. Box 14165 address.11CarePlus Health Plans. Appeals If CarePlus upholds the denial, the case automatically moves to a Level 2 review by an Independent Review Organization that has no affiliation with the plan.