Preauthorization Lists

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

Disclaimer

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

Visit your member portal to look up benefits, check your claim status, and much more.

- or -

Allegian Health Plans, 4801 NW Loop 410 Ste. 300, San Antonio, TX 78229

Main Number (855) 381-3442
TRS-ActiveCare Members (855) 463-7264