SOMOS Prior Authorization Form: Medical, Behavioral Health, and Appeals

The SOMOS prior authorization form is the request a provider submits to SOMOS Community Care before delivering certain services to a Medicaid managed care member assigned to the SOMOS network in New York. SOMOS publishes two versions, one for medical services and one for behavioral health, and both are downloadable from the provider resources page at somosinnovation.com.¹ SOMOS handles utilization management for members enrolled through participating plans, including Medicaid Managed Care, Health and Recovery Plan, Child Health Plus, and Essential Plan.²

Pick the Right Form First

Using the wrong form slows the request down. The Medical Authorization Request Form covers inpatient admissions, outpatient surgeries, imaging, therapies, durable medical equipment, and similar clinical services. The Behavioral Health Authorization Request Form covers inpatient mental health, inpatient chemical dependency, outpatient counseling, psychiatric testing, intensive outpatient programs, partial hospitalization, residential treatment, and community-based behavioral health services.¹ Both share the same patient and provider information sections, but the behavioral health version adds a symptom checklist and medication history.

Which Services Need Authorization

Prior authorization through SOMOS applies to inpatient services, outpatient services, radiology, and medical injectable approvals, among others.² The medical form itself breaks these out into specific categories you check off:

Inpatient categories: emergency inpatient, concurrent review, long-term acute care, skilled nursing facility, rehabilitation, transplant, maternity, and elective admission or surgery.
Outpatient categories: surgical procedures, imaging, physical therapy, occupational therapy, speech therapy, chemotherapy, pain management, cosmetic or reconstructive procedures, DNA or genetic testing, orthotics and prosthetics over $750, lab services, and sleep studies.

The full list depends on your contract with the member’s health plan. Check the back of the member’s ID card for plan-specific contact information, and refer to your provider contract for the complete list.³

Completing the Medical Form

Every required field must be filled in. SOMOS rejects and returns incomplete forms, so a sloppy first submission can eat up most of your determination window.⁴

Requestor and Patient Information

Start with the requestor’s contact name and phone number. This is the person SOMOS calls if clarification is needed. Then enter the patient’s legal name, date of birth, Member ID, and phone number. Three screening questions follow: whether the service relates to a work injury, a motor vehicle accident, or whether the member carries other insurance or Medicare (and if so, Part A or Part B). These answers drive coordination of benefits, so answer them accurately even when the answer seems obviously no.

Urgency Level

Mark the request Elective/Routine or Expedited/Urgent. Expedited triggers a 72-hour review track, but it is reserved for situations where a delay could seriously jeopardize the member’s health or ability to regain maximum function.⁵ Do not mark requests urgent just to move them faster. Inappropriate use of the designation draws scrutiny on later requests.

Service Type and Procedure Codes

Check the service category that matches the request. Then enter the ICD-10 diagnosis code with a short description, the CPT or HCPCS procedure codes for each requested service (with units and frequency for supplies), the dates of service, and the number of visits.⁴ A mismatch between the category you check and the CPT code you enter is one of the easiest ways to get the form kicked back. Double-check both before you submit.

Provider and Facility Information

The form has fields for up to three providers: the ordering provider (and whether they are the member’s primary care physician), the servicing provider (with a checkbox if the same as ordering), and the facility where the service will happen. For each, provide name, NPI, TIN, phone, fax, and address. Asterisked fields are required.⁴

Clinical Documentation

Attach every piece of supporting clinical information: lab results, imaging reports, operative notes, specialist consultation letters, anything that establishes medical necessity. The form warns that lack of clinical information may result in a delayed determination.⁶ This is where most denials originate. A submission that says “patient needs MRI” without explaining failed conservative treatment or the clinical findings pointing to the diagnosis will not survive medical necessity review. Attach more than you think you need.

What Changes on the Behavioral Health Form

The behavioral health form uses the same demographics, urgency selection, procedure code, and provider sections as the medical form. The service categories differ, and the clinical detail required is deeper.

Service Types

Instead of medical inpatient and outpatient categories, the behavioral health form lists inpatient mental health, inpatient chemical dependency, outpatient counseling, psychiatric testing, intensive outpatient programs, electro-convulsive therapy, partial hospitalization, residential treatment center, and community-based services or case management.

Symptom Checklist and Medication History

A detailed symptom checklist is organized by category: psychosis, anxiety, safety concerns, mood disturbance, substance use, and developmental disorders. For substance use, provide a CIWA, COWS, or CINA score if applicable, along with history of withdrawal seizures or delirium tremens. A separate section covers current psychiatric or medical medications, with fields for medication name, dosage, and the member’s response. The progress indicator (improved, unchanged, or regressed) shows the trajectory of the member’s condition.

Care Coordination

The behavioral health form adds a care coordination section asking for contact information for the utilization review department, the discharge planner, and the health plan care coordinator. This section is not on the medical form. As with the medical version, attach clinical notes and summaries; incomplete information delays the review.⁶

How to Submit

You can submit the completed form through the SOMOS provider portal or by fax. As of March 16, 2026, the SOMOS provider portal transitioned to Availity, replacing the previous system.¹ If you have not set up an Availity account, the SOMOS provider resources page links to the registration. For portal submissions, log in, go to the authorization section, and upload the completed form along with your clinical attachments.

For fax, call the SOMOS prior authorization line at (844) 990-0255 to confirm the correct fax number for your request type. Medical and pharmacy requests may route to different intake lines.² Keep the fax confirmation page. It documents the date and time of submission and protects you if there is any dispute about whether the request was timely.

When to Expect a Decision

New York State sets the clock. Standard requests must receive a determination within three business days after SOMOS has all necessary information, and the outer limit cannot exceed 14 calendar days from receipt of the initial request.⁷ Expedited requests must be decided within 72 hours of receipt. Either the enrollee, the provider, or the plan can request an extension of up to 14 additional calendar days on standard or expedited timelines, but plan-initiated extensions require justification that the delay is in the member’s interest.⁵

Retrospective review requests, where the services have already been delivered and authorization is being sought after the fact, have a 30-day determination window after all information has been received.⁷

Emergency Services Do Not Need Authorization

Emergency medical screening and stabilization never require prior authorization. Federal law under EMTALA requires Medicare-participating hospitals to provide a medical screening examination and stabilizing treatment for any emergency medical condition regardless of ability to pay or insurance status.⁸ For Medicaid managed care members, plans cannot deny payment for emergency services that a prudent layperson would reasonably consider an emergency, even without prior authorization. Once the member is stabilized, authorization requirements can resume for post-stabilization services, so get the request submitted as soon as the clinical picture allows.

If the Request Is Denied

When SOMOS denies a prior authorization request, both the provider and the member receive notice. The member’s notice explains the reason and outlines appeal rights. The process has two levels: an internal plan appeal and, if that fails, a state Fair Hearing.

Internal Plan Appeal

The member has 60 calendar days from the date of the denial notice to file an internal appeal with the health plan. The plan must resolve a standard appeal within 30 business days. Expedited appeals, where delay could jeopardize the member’s health, must be decided within two business days of receiving all information, and no later than 72 hours total.⁷

Before the plan issues a final adverse determination, a reviewer may contact the requesting provider for a peer-to-peer discussion. That pre-determination conversation is your best chance to change the outcome, because new clinical context can still directly influence the decision. Once a final determination has issued, a peer-to-peer call is purely informational. It cannot reopen the case. Any new clinical evidence after that point has to go through the formal appeals process.

Fair Hearing

If the internal appeal is denied, the member can request a Fair Hearing through the New York State Office of Temporary and Disability Assistance within 120 days of the final adverse determination.

Aid to Continue

A member disputing the termination, suspension, or reduction of a previously authorized service can keep receiving that service while the appeal or Fair Hearing is pending, but only if they move fast. To preserve benefits during an internal appeal, the member must request the appeal within 10 days of the denial notice or by the effective date of the action, whichever is later. The same 10-day window applies to preserving benefits during a Fair Hearing after the plan appeal is denied.⁹ Miss the 10-day window and the service stops while the appeal works its way through. Flag this deadline for the patient the moment a denial comes in.

1
SOMOS Innovation. Provider Resources – Tools, Info, and Resources for SOMOS Partners
2
Empire BlueCross BlueShield HealthPlus. Utilization Management and Claims Submission for SOMOS Members
3
EmblemHealth. Claims Submission and Utilization Management for SOMOS Community Care
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SOMOS Innovation. SOMOS Medical Authorization Request Form
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eCFR. 42 CFR 438.210 – Coverage and Authorization of Services
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SOMOS Innovation. SOMOS Prior Authorization Form
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New York State Department of Health. New York State Medicaid Managed Care Service Authorization and Appeals Timeframe Comparison
8
Centers for Medicare & Medicaid Services. Emergency Medical Treatment and Labor Act (EMTALA)
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New York State Department of Health. Aid to Continue