How to Fill Out and Submit the ATRIO Prior Authorization Request Form

To request advance approval for a service for an ATRIO Medicare Advantage member, complete the ATRIO prior authorization request form — a one-page PDF available on the provider section of atriohp.com — attach the clinical records that support medical necessity, and fax the packet to the review team assigned to the member’s Oregon county. Pharmacy (Part D) requests do not use this form; those go through CoverMyMeds.¹

First, Check Whether the Service Needs Authorization

Not every service requires advance approval. ATRIO publishes a prior authorization grid each year listing the CPT and HCPCS codes and service categories that trigger the requirement. Before you open the form, pull the current grid and look up the code. If the service isn’t on the grid, you don’t need to submit anything.²

Categories currently on the grid include inpatient hospital admissions, skilled nursing facility stays, home health, non-emergency ambulance transport, cardiac and pulmonary rehab beyond 36 visits per plan year, PPO therapy visits beyond the first 20 combined per plan year, durable medical equipment rentals, DME or prosthetic purchases over $750 per line item, all continuous blood glucose monitors, hospital outpatient and ambulatory surgery center procedures, advanced imaging (CT angiography, MRI, PET), and genetic testing.²

One boundary worth flagging: starting February 1, 2026, skilled home health authorizations are managed through the Tango platform at pronetconnect.com rather than through this form.²

Completing the Form

The form is a single page divided into labeled sections. Fields marked with an asterisk are required, and a missing required field is the fastest way to get the request kicked back.³

Requestor and Member Information

At the top, enter the date, the name of the person completing the form, the provider or clinic name, and a phone and fax number. In the member section, enter the patient’s full name, date of birth, and ATRIO member ID exactly as it appears on the front of the insurance card. A single transposed digit in the member ID sends the request to the wrong file.³

Requesting Provider

Enter the requesting provider’s name, check the credential box (MD, DO, FNP, NP, or PA), and supply a phone number, fax number, and 10-digit NPI. If an appointment is already on the calendar, add that date. The form does not ask for a Tax Identification Number here; the TIN is used separately when registering for the provider portal.³

Delivering Provider or Facility

This section tells the reviewer where the service will actually happen. Enter the delivering provider or facility name, NPI, and phone number, and list the ICD-10 diagnosis codes that justify the service. If you are requesting an out-of-network facility, use the “Other important information” field at the bottom of the form to explain why no in-network option is suitable.³

Procedure, Service, and Surgery Details

List each CPT or HCPCS code with any modifier, a plain-language description, the number of units, and the requested start and end dates. For surgical requests, check whether the procedure is outpatient hospital or ambulatory surgery center, and note whether an inpatient stay is expected and when. Reviewers match the codes against ATRIO’s coverage criteria, so a wrong code can produce a denial even when the underlying service would have been approved.³

Clinical Documentation to Attach

The form by itself rarely tells the whole story. Attach records that show why this service is medically necessary for this specific patient: recent office visit notes, relevant labs, and imaging reports. If step therapy applies, document the less intensive treatments the patient has already tried and how they turned out. A complete clinical picture lowers the chance of a denial based on insufficient information.

Where to Fax the Packet

Fax is the primary submission method, and ATRIO routes requests to different medical review teams by the member’s Oregon county. Sending to the wrong number can delay a decision by days, so confirm the routing before you hit send.¹

Klamath County: 1-541-882-6914
Jackson and Josephine Counties (Asante PCP or PCP unknown): 1-866-500-8773
Douglas, Lane, Yamhill, Marion, Polk, Clackamas, Washington, and Multnomah Counties (and Jackson or Josephine members with a non-Asante PCP): 1-503-581-7422 for most prior authorizations, or 1-503-485-3220 for SNF and hospital requests

These numbers are printed on the form itself. Whenever possible, fax the completed form and all supporting documentation in a single transmission.³

Pharmacy Requests Use a Different Path

Part D drug coverage determinations do not use this form. Submit those electronically through CoverMyMeds, which connects directly to ATRIO’s pharmacy review team. The ATRIO-specific forms are at covermymeds.com/main/prior-authorization-forms/atrio-health-plans/.¹

When to Expect a Decision

As of January 1, 2026, CMS requires Medicare Advantage plans to decide standard prior authorization requests within seven calendar days of receipt, down from the previous 14-day window.⁴ Expedited requests, used when waiting could seriously jeopardize the patient’s life, health, or ability to regain maximum function, must be decided within 72 hours.⁵

Part B drug requests run on their own clock: ATRIO must respond within 72 hours whether or not the request is marked urgent, and that timeframe cannot be extended.⁴

Also beginning in 2026, when ATRIO denies a prior authorization, the plan must give a specific reason rather than a generic notice, no matter whether the decision comes by portal, fax, email, mail, or phone. Drug coverage determinations are excluded from that requirement.⁵

If the Request Is Denied

The written denial notice must explain the reason and describe the member’s appeal rights. Under Medicare Advantage rules, you have 60 calendar days from the date on the notice to file a first-level appeal, called a reconsideration, with the plan.⁶

ATRIO publishes a Provider Appeal Form for first-level appeals. For medical services, standard appeals are decided within 30 calendar days; an expedited appeal is available when waiting could seriously harm the patient’s health or ability to recover. Part D appeals run on a seven-calendar-day standard timeframe, with expedited review also available.⁷

Many Medicare Advantage plans also allow the treating physician to request a peer-to-peer conversation with the plan’s medical director before or shortly after a formal denial. If ATRIO offers peer-to-peer review for a particular denial, contact information will usually appear in the denial notice or can be obtained from provider services. A peer-to-peer call does not replace the formal appeal, but it can sometimes resolve the issue faster.

If the first-level appeal upholds the denial, the case moves automatically to an independent review entity contracted by CMS for a second-level review. Neither the member nor the provider has to file anything to trigger that external review.⁶

1
ATRIO Health Plans. Prior Authorizations
2
ATRIO Health Plans. 2025 Medicare Prior Authorization Grid
3
ATRIO Health Plans. ATRIO Health Plans Prior Authorization Request Form
4
eCFR. 42 CFR 422.568 – Standard Timeframes for Making Determination
5
Centers for Medicare & Medicaid Services. CMS Interoperability and Prior Authorization Final Rule CMS-0057-F
6
Centers for Medicare & Medicaid Services. Reconsideration by the Medicare Advantage (Part C) Health Plan
7
ATRIO Health Plans. Provider Appeal Form – 1st Level of Appeal