MAP and Charity Prior Authorization
Medical Access Program and Charity Program Prior Authorization Resources
Below is a collection of forms and resources to help providers easily access and download prior authorization forms, non-covered and plan limitations lists, and the UM prior authorization process for MAP and Charity program members.
Forms and resources
- MAP Prior Authorization list | MAP Non Covered List & Plan Limitations
Download these forms to view what CPT/HCPCS codes require a prior authorization, are not covered or have a plan limitation for MAP members. - Sleep Study Authorization Form utilized for MAP members
Download this form to request a sleep study prior authorization for MAP members. - MAP & Charity Prior Authorization Form
Download this form to request a prior authorization for MAP & Charity members. - Charity Prior Authorization list | Charity Non Covered list & Plan Limitations
Download these forms to view what CPT/HCPCS Codes require a prior authorization, are not covered or have a plan limitation for Charity members. - UM Prior Authorization Process
Download this document to view the prior authorization form instructions. This form helps you identify what fields need to be completed, how to submit a prior authorization request and includes a listing of the turnaround time for the prior authorization requests. - MAP Prior Authorization List Effective 2/1/2025
- MAP Non-Covered List Effective 2/1/2025
- Charity Prior Authorization List Effective 2/1/2025
- Charity Non-Covered List Effective 2/1/2025
How to submit files and forms
Once the forms are downloaded and completed, please fax to 512-380-4253.