Please answer all of the following questions to determine if an authorization is needed:

Types of Services Yes No
Are services being provided by an out-of-network Provider?
Is the member being admitted to an inpatient facility?
Is the member receiving oral surgery services?
Is the member receiving plastic and reconstructive surgeon services?


To determine if an authorization is needed enter CPT code below.
CPT code: 1:        2:        3:        4: