Health Maintenance Organization (HMO)
Preferred Provider Organization (PPO)
Texas Authorization Form
Self-Funded Pre-Certification Requirements
Prior Authorization List (Effective 7/1/16)
Prior Authorization Form
While every effort has been made to provide the most accurate and up-to-date information, these lists are subject to change.
Please note that Prior Authorization is not a guarantee of payment. It is a pre-service determination of medical necessity based on information provided at the time the prior authorization request is made. Allegian Health Plans retains the right to review the medical necessity of services, eligibility for services, and benefit limitations and exclusions after you receive the services.
If you have any questions about prior authorization requirements, please contact customer service at 855-381-3442 or write to:
Allegian Health Plans
1596 Whitehall Road
Annapolis, MD 21409