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IMPORTANT: Sending Authorization Forms to the Correct Fax Number Based on Member Insurance

Date: 09/25/25

To support timely and accurate processing of prior authorization requests, providers must fax the correct forms to the corresponding fax number on the form based on the member’s insurance and needed service (i.e. medical or behavioral health). Misrouted or incorrect submissions may result in delays in care and additional administrative burden.

Avoid These Common Errors

  • Faxing forms to outdated or incorrect numbers.
  • Using the wrong form for the member’s plan type.
  • Submitting without verifying eligibility or plan details.

Authorization Fax Forms

Please use the appropriate form and fax number for each member’s insurance and service type.

Ambetter (Marketplace)

Please use the following fax forms that can be found under the Medical Management section of Ambetter’s Provider Resources webpage:

  • Inpatient Prior Authorization Fax Form (PDF)
  • Outpatient Prior Authorization Fax Form (PDF)

Medicaid and CHIP

Please use the following fax forms that can be found under the Medicaid Prior Authorization Forms section of Superior’s Provider Forms webpage:

  • Inpatient Medicaid Authorization Form (PDF)
  • Outpatient Medicaid Authorization Form (PDF)

Wellcare By Allwell (Medicare)

Please use the following fax forms that can be found under the Medicare Acute Care Services section of Superior’s Provider Forms webpage:

  • Inpatient Medicare Authorization Fax Form (PDF)
  • Outpatient Medicare Authorization Fax Form (PDF)

How to Ensure Correct Submission

  • Always verify the member’s insurance prior to submitting.
  • Use the correct form and the appropriate fax number indicated on the form.
  • Contact Provider Services if you are unsure which form to use.

For more information, please contact your Provider Representative. To access their contact information visit Find My Provider Representative.