The Optimum prior authorization form — officially the Pre-Certification Request Form — is what providers submit to Optimum HealthCare’s Utilization Management (UM) department to get advance approval for certain covered services. You can download it from the provider forms page at youroptimumhealthcare.com or submit the request directly through the provider portal. The form collects member details, diagnosis and procedure codes, and a clinical statement, then goes to UM for a medical-necessity review.
When You Need to Submit the Form
Not every service requires advance approval, so check Optimum HealthCare’s prior authorization list first. In most cases the member’s primary care physician (PCP) is responsible for submitting the request. The main categories that trigger the requirement:1Optimum HealthCare. Referrals and Advance Approvals for Services
- Surgery and inpatient care, including all outpatient hospital services, certain ambulatory surgery center procedures (blepharoplasty, septoplasty, vein treatments, pain management injections, and others), inpatient hospital stays, acute rehabilitation facilities, skilled nursing facilities, and transplants.
- High-tech imaging: PET scans, pill endoscopy, and virtual endoscopy. Standard CT scans and MRIs at free-standing radiology centers need a referral, not a prior authorization.
- Durable medical equipment with a purchase price above $500, plus all wheelchairs, hospital beds, CPAPs, BiPAPs, oxygen equipment, TENS units, wound-care supplies, and nerve or bone growth stimulators regardless of cost.
- Cardiac, pulmonary, and respiratory rehabilitation; any outpatient hospital rehab; and office-based physical, occupational, or speech therapy beyond 10 visits.
- Chemotherapy, radiation therapy, pain management, injectable or infusion therapy, home health services, genetic testing, implantable devices, orthotics or prosthetics over $500, enteral feedings, and non-participating provider services.
Specialty medications billed under Part B J-codes use a separate Specialty Medication Form instead of the standard Pre-Certification Request Form, and get faxed to a dedicated line at (888) 736-1123 or (813) 506-6226.2Optimum HealthCare. Specialty Medication Request Form Optimum also publishes a Part B Drugs List of medications that do not require authorization at all.3Optimum HealthCare. Optimum HealthCare – Forms
Filling Out Each Section
The form is laid out in distinct sections. Working through them in order is the fastest way to avoid a rejection for missing information.4Optimum HealthCare. Pre-Certification Request Form
Expedited Request
Complete this section only if the standard review timeline could seriously harm the member’s health or ability to recover. Medicare defines an expedited request as one where the standard timeframe “could seriously jeopardize the life or health of an enrollee or the enrollee’s ability to regain maximum function.” The treating physician must document the reason on the form and sign it. Leave this blank for routine requests.
Member Information
Enter the member’s full name, date of birth, and the Plan ID number printed on the front of their member card. Verify the ID digit by digit. A single transposition can delay processing or misroute the request.
Requesting Provider
Fill in the date of the request and the county. The form includes a PCP attestation: confirm whether you are the member’s PCP or acting as the PCP’s agent, then sign. Requests that do not come from the PCP get reviewed with the PCP before a decision is made, which adds time. Enter the requesting provider’s name, Tax Identification Number (TIN), phone and fax numbers, contact person, and extension.
Facility and Provider Requested
If the service will be performed at a facility (hospital, surgery center, skilled nursing facility), list the facility’s full name without abbreviations, its TIN, address, phone, and fax. Do the same for the individual provider who will perform the service. Mark the non-participating provider box if either one is outside the Optimum network.
Diagnosis and Procedure Codes
Enter the ICD-10 diagnosis codes that describe the member’s condition. The form has room for two separate diagnosis lines, so list primary and secondary diagnoses if relevant. Below the diagnosis lines, enter the CPT or HCPCS procedure codes, a written description of each service, and the number of visits or injections requested. Transposed digits in these codes are the most common reason for processing delays, so verify each one against the member’s chart before submitting.
Clinical Statement
The form asks for a short clinical statement supporting the request. Explain in plain terms why the service is medically necessary: what the member’s condition is, what conservative treatments have already been tried, and why the requested service is the appropriate next step. This is the summary the plan’s medical director reads first. The attachments carry the full clinical picture.
What to Attach
Include the most recent progress notes showing the member’s current condition, relevant lab results, and diagnostic imaging reports (MRIs, CT scans, X-rays) that support the request. If the service is a step up from conservative treatment, document what was tried and why it was insufficient.
Under HIPAA’s minimum-necessary standard, share only the information needed to justify the requested service, not the member’s entire medical record.5U.S. Department of Health and Human Services. Minimum Necessary Requirement Too little documentation forces a request for more and delays the decision. An unfiltered chart dump creates privacy concerns and buries the relevant findings.
How to Submit
You have three ways to get the completed form to UM.
Provider Portal
The provider portal at apps.youroptimumhealthcare.com is the fastest submission method.6Optimum HealthCare. Medicare Quick Reference Guide Portal submissions generate an electronic confirmation and give you 24-hour access to check eligibility and authorization status. If a dispute later arises about when a request was submitted or what it contained, the portal’s digital trail is your proof.
Fax
If you submit by fax, use the fax number designated for the service type. For specialty medication requests, the dedicated lines are (888) 736-1123 and (813) 506-6226.2Optimum HealthCare. Specialty Medication Request Form Keep the fax confirmation page showing the date, time, and number of pages transmitted. That page is your primary evidence if the plan later says the request was never received.
Phone
The UM department takes provider calls at 1-866-409-0888, Monday through Friday, 8 a.m. to 5 p.m. After hours, the same number connects to an on-call nurse for urgent authorization assistance. The plan’s Medical Director is also available during business hours at that number to discuss a UM decision with the treating physician.7Optimum HealthCare. Utilization Management
How Long the Decision Takes
Federal regulations set hard deadlines for how quickly a Medicare Advantage plan must respond. As of January 1, 2026, the timelines depend on what type of service is involved.
- Standard requests for services subject to § 422.122 prior authorization rules: 7 calendar days from receipt.8eCFR. 42 CFR 422.568 – Standard Timeframes and Notice Requirements for Organization Determinations
- Standard requests for services not subject to those rules: up to 14 calendar days.
- Part B drug requests: 72 hours, no extensions allowed.
- Expedited requests for services or items: 72 hours when the plan agrees the request qualifies as expedited.9eCFR. 42 CFR 422.572 – Timeframes and Notice Requirements for Expedited Organization Determinations
- Expedited Part B drug requests: 24 hours, no extensions.
The plan can extend a standard or expedited service request by up to 14 additional calendar days if the member asks, if the plan needs records from an out-of-network provider, or if extraordinary circumstances justify the delay. The plan must notify the member in writing with the reason and explain the right to file an expedited grievance over the delay.8eCFR. 42 CFR 422.568 – Standard Timeframes and Notice Requirements for Organization Determinations
If the Request Is Denied
Optimum must send a written denial notice to both the member and the provider stating the specific reasons for the decision and describing the appeals pathway, starting with reconsideration.8eCFR. 42 CFR 422.568 – Standard Timeframes and Notice Requirements for Organization Determinations
To request a standard reconsideration, the member (or the treating physician on the member’s behalf after notifying the member) must file a written request within 60 calendar days of receiving the denial. The clock starts 5 days after the date on the notice unless there is evidence the member received it sooner or later. The plan can grant an extension for good cause.10eCFR. 42 CFR Part 422 Subpart M – Grievances, Organization Determinations, and Appeals
An expedited reconsideration is available when a standard-timeline review could seriously jeopardize the member’s health. Either the member or a physician (even one not affiliated with Optimum) can request it orally or in writing, within the same 60-day window. If the plan denies the expedited reconsideration, the case moves to an independent review entity.
Common Reasons for Delay
Most rejections come down to avoidable paperwork problems rather than genuine medical-necessity disputes.
- Verify ICD-10 and CPT/HCPCS codes before submitting. A transposed digit triggers an automatic rejection before a clinical reviewer ever sees the case.
- Submit through the PCP. Requests that bypass the PCP get routed back for review, which adds days.4Optimum HealthCare. Pre-Certification Request Form
- Spell out the facility name. The form explicitly says “No Abbreviations.” Abbreviations can create mismatches with the plan’s provider directory and slow credentialing verification.
- Attach clinical documentation up front. Submitting without records almost guarantees a request for additional information, which restarts the review clock.
- Use the portal when possible. It gives you a timestamped confirmation and lets you check status without calling.
Providers can check the status of a pending authorization by logging into the portal or calling UM at 1-866-409-0888 during business hours.7Optimum HealthCare. Utilization Management Status updates often appear on the portal before the formal determination letter is mailed.