Online Provider Authorization

Provider Information

Provider
Facility or company

Provider's last name:

Provider's first name and middle initial:

Facility / Company name:

Billing provider:

NPI:

Tax ID(TIN):

Street address:

City:

State:

Zip code:

Phone number:

Fax number:

Provider's Contact Information

Contact name:

Contact phone number:

Contact email address:

Confirm email address:

Patient Information

Last name:

First name:

DMBA ID number:

Date of birth:

DMBA medical plan:

Deseret Choice Hawaii
Deseret Premier
Deseret Protect
Deseret Select
Student Plan
Deseret Value
Plan Z

Subscriber's name:(if not the patient's name)

Dental Service Information

Diagnostic code(s):

Procedure code(s) : (Please put any additional codes in comments box below)

Location of service:

Frequency of service:

Medical Service Information

Diagnostic code(s):

Procedure code(s) : (Please put any additional codes in comments box below)

Location of service:

Frequency of service:

Surgical Service Information

Diagnostic code(s):

Procedure code(s) : (Please put any additional codes in comments box below)

Location of service:

Inpatient Medical Service Information

Diagnostic code(s):

Procedure code(s) : (Please put any additional codes in comments box below)

Location of service:

Requested length of stay:

Inpatient Surgical Service Information

Diagnostic code(s):

Procedure code(s) : (Please put any additional codes in comments box below)

Location of service:

Requested length of stay:

Mental Health - Alternative Care (Residential, PHP, IOP) Service Information

Diagnostic code(s):

Procedure code(s) : (Please put any additional codes in comments box below)

Location of service:

Requested length of stay:

Mental Health - Inpatient Service Information

Diagnostic code(s):

Procedure code(s) : (Please put any additional codes in comments box below)

Location of service:

Requested length of stay:

Mental Health - Other Service Information

Requested service:

Outpatient therapy

Outpatient electroconvulsive therapy (ECT)

Psychological testing

Neuropsychological testing

Diagnostic code(s):

Procedure code(s) : (Please put any additional codes in comments box below)

Location of service:

Frequency of service:

SNF/Rehab/LTAC Service Information

Diagnostic code(s):

Procedure code(s) : (Please put any additional codes in comments box below)

Admitting facility:

Admitting level of care:

Home Health Service Information

Disclaimer: Home health aides are not a covered benefit on any plan.

Check all that apply:

Enteral formula

Hospice

Medication

Occupational therapy

Physical therapy

Skilled nursing

Social work

Speech therapy

Diagnostic code(s):

Procedure code(s) : (Please put any additional codes in comments box below)

Frequency of service:

Length of service:

Durable Medical Equipment Information

Is this a new request?

Yes No

Type of request?

Rental Purchase

Requested service:

Bedside oximeter/apnea monitor
Hospital bed
Insulin pump/continuous glucose monitoring device
Oxygen therapy
CPAP
Bi-PAP
Wheelchair
Other

Diagnostic code(s):

HCPCS code(s):

Length of need:

Medication Information

DMBA only requires preauthorization for certain medications when administered in a physician’s office, an infusion center, or at home with skilled nursing. If you have questions about a specific medication, please contact us at 801-578-5600 or 800-777-3622.

To authorize any of these drugs, please contact Archimedes Rx:

888-504-5563
https://archimedesrx.com/resources/

Specialty drugs not included on the medical pharmacy drug list may require preauthorization through Navitus Health Solutions. For questions, please call Navitus at 833-354-2226.

Deseret Alliance participants enrolled in the Navitus MedicareRx (PDP) may be required to preauthorize specialty pharmacy medications. Deseret Alliance members may use any Navitus contracted specialty pharmacy, but we recommend Lumicera Health Services. To contact Lumicera:

call 855-847-3554, or
fax 855-847-3558

The medication will be given:

At home with skilled-nursing
In a doctors office
In an Infusion Center

Diagnostic code(s):

J-Code(s):

Frequency of service:

Speech Therapy Service Information

Diagnostic code(s):

Procedure code(s) : (Please put any additional codes in comments box below)

Frequency of therapy:

Length of service:

IVF Information

Diagnostic code(s):

Procedure code(s) : (Please put any additional codes in comments box below)

Is the provider board-certified in reproductive endocrinology and infertility?

Yes
No

When does the REI certification expire?

How long have the partners been married?

How long has the patient been attempting to conceive with this partner?

Is there a history of voluntary sterilization and reversal?

Yes
No

Is this related to a surrogacy?

Yes
No

Total number of pregnancies?

Number of completed IUI cycles?

Number of completed IVF cycles?

Location of service:

ABA Information
* Note: Preauthorization is not required for the initial evaluation/ assessment

Diagnostic code(s):

Procedure code(s) : (Please put any additional codes in comments box below)

Diagnosing Provider:

Current age of child:

Is therapy provided under an IEP?:

Yes
No

Frequency of service:

Planned place of service:

Genetic Testing Information

Diagnostic code(s):

Procedure code(s) : (Please put any additional codes in comments box below)

Has genetic counseling been done? (Please attach genetic counseling notes).

Yes
No

Prosthetics Information

Diagnostic code(s):

Procedure code(s) : (Please put any additional codes in comments box below)

Location of service:

Transplant Information

Diagnostic code(s):

Procedure code(s) : (Please put any additional codes in comments box below)

Transplant type:

Autologous BMT / SCT
Autogeneic BMT / SCT
Heart
Heart / Kidney
Heart / Lung
Kidney
Kidney / Lung
Kidney / Pancreas
Liver
Liver / Intestine
Liver / Kidney
Liver / Lung
Lung
Pancreas
Small Bowel / Intestine

Bariatric Surgery Information

Diagnostic code(s):

Procedure code(s) : (Please put any additional codes in comments box below)

Location of service:

Total Hip or Knee Replacement Information

Diagnostic code(s):

Procedure code(s) : (Please put any additional codes in comments box below)

Location of service:

Delete Record

Title

Updates and Requests

Electronic Transactions

Preauthorization

Plan Benefit Summaries

Policies and Procedures

Medical Providers

Mental/Behavioral Health Providers

Dental Providers

Other Providers

Medicare Providers

DMBA YouTube Video Player

Provider Authorization Request