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Standardized Prior Authorization Form

The standardized prior authorization form was developed in May 2012 by the Massachusetts Health Care Administrative Simplification Collaborative, an organization committed to reducing health care administrative costs. Its goal is to streamline the data submission process for certain services that require prior authorization.

The form was not intended to replace the prior authorization processes, policies and documentation requirements of specific health plans. Instead, it was created to serve as a standardized prior authorization form accepted by multiple health plans, including UniCare.

Providers can use the prior authorization form to submit a prior authorization request to UniCare for review. But they will still need to submit the appropriate UniCare pre-certification worksheet to provide the necessary clinical documentation to support the request. (UniCare does not require providers to submit the standardized prior authorization form – only the appropriate UniCare pre-certification worksheet.)

Note: We have modified the prior authorization form to add our plan name and fax number. We have also “grayed out” certain services that UniCare either doesn’t cover or doesn’t require preauthorization for.

How to use the standardized prior authorization form

View the reference guide for the standardized prior authorization request, prepared by the Massachusetts Health Care Administrative Simplification Collaborative.

Services the form doesn’t apply to

Questions? Call UniCare at (800) 442-9300.


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