Prior Authorization Requirements
*New!* Authorization Structure for Claims billed
on Dates-of-Service Effective 5/1/2026
Authorization Requirements for PACE (Program of All-inclusive Care for the Elderly), Family Care Partnership, and Family Care Program
All authorization-related forms for Medical and Long-term Care, for each program, are linked below.
Family Care Partnership
- FCP Bariatric and Transplant Surgery Prior Authorization Request Form
- FCP Genetic Testing and Molecular Pathology Prior Authorization Request Form
- FCP Hospice Prior Authorization Medicaid Only Form
- FCP Hyperbaric Oxygen Treatment Prior Authorization Request Form
- FCP Pain Management Prior Authorization Request Form
- FCP Physician Administered Medication Prior Authorization Request Form
- FCP Post-Acute Facility Prior Authorization Request Form
- FCP Post-Acute Facility Continued Stay Review Form
- FCP SPECT & PET Imaging Prior Authorization Request Form
- FCP Surgery Prior Authorization Request Form
PACE (Program of All-Inclusive Care for the Elderly)
- PACE Bariatric and Transplant Surgery Prior Authorization Request Form
- PACE Genetic Testing and Molecular Pathology Prior Authorization Request Form
- PACE Other Medical Services Prior Authorization Request Form
- PACE Physician Administered Medication Prior Authorization Request Form
- PACE Post-Acute Facility Prior Authorization Request From
- PACE Post-Acute Facility Continued Stay Review Form
- PACE SPECT & PET Imaging Prior Authorization Request From
Family Care Program
For Providers billing from 6-1-25 through 4-30-26, please use the previous Prior Authorization Requirement document.
