Outpatient Authorization Request Form - Blue Cross and …
https://providers.bcbsla.com/-/media/Files/Providers/Blue%20Advantage%20Resources/2022-12%20Outpatient%20Authorization%20Request%20Form%20pdf.pdf
WEBThe purpose of this form is to request a prior authorization for outpatient services and Part B drugs. Please fax this completed form to 1-877-528-5816, Attn. Medical Management. If you have questions about this form, contact Blue Advantage Authorizations Department at 1-866-508-7145, choose option 3, then option 3.
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