CurrentAetnaPolicy N/A

Illinois Uniform Electronic Prior Authorization Form for Prescription Benefits

This document is the Illinois-mandated uniform electronic prior authorization form for prescription drug benefits, for use by prescribing providers to request prior authorization from commercial health insurers regulated by the Illinois Department of Insurance. It governs submission, timelines, and required information for prior authorization requests for prescription drugs for insured patients in Illinois.

Policy Summary

PayerAetna

PolicyIllinois Uniform Electronic Prior Authorization Form for Prescription Benefits

Policy CodePolicy N/A

Change TypeAdministrative (no material clinical changes)

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests online at Availity.com or use the provided fax/phone options to send the completed form to the patient's health plan.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 / 72hinsurer response timeline (urgent/regular)

Availityonline portal

1-855-240-0535fastest service phone

1-877-269-9916 / 1-866-249-6155fax numbers

Illinois-only

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Coverage and Procedural Criteria

Coverage and procedural criteria

Form instructions clarify that prior authorization is required by the health plan and that approval via this form does not override plan terms.

If the form is incomplete or insufficient clinical information is provided, the insurer may request additional information; this may extend the review period or result in an adverse determination.

Insurers may require follow-up inquiries for additional clinical information depending on the type of prescription drug requested.

If a completed and accurate electronic prior authorization request is received, statutory timelines for insurer response apply (see statute); failure to respond within those timelines may have statutory effects as provided by law.

Prior authorization via this form does not override other plan requirements such as step therapy or formulary exception processes that may still be required by the insurer or statute.

Diagnosis Coding and Response Timelines

Diagnosis codingICD-10

ICD	Diagnosis ICD# requested on form

Insurer response time threshold — urgent 24 hours; regular 72 hours

Urgent (Expedited) response timeInsurer must respond within 24 hours when the patient has urgent medication needs.

Regular response timeInsurer must respond within 72 hours when the patient has regular medication needs.

Deemed grant upon missed timelineIf insurer fails to respond within the applicable timeline after receipt of a completed, accurate electronic PA request, the request is deemed granted under 215 ILCS 5/364.3(f).

Submission, Timelines, Required Fields, and Notices for Providers

Prior Authorization

Submission and contact

Submit prior authorization requests online at www.Availity.com. For fastest service, call 1-855-240-0535, Monday–Friday, 8 a.m. to 6 p.m. Central Time. Fax submissions are accepted: non-specialty drug PA Fax 1-877-269-9916 and specialty drug PA Fax 1-866-249-6155. Do not send completed forms to the Illinois Department of Insurance; submit only to the patient’s health plan.

Online portal: www.Availity.com
Phone (fastest service): 1-855-240-0535 (Mon–Fri, 8 a.m.–6 p.m. CT)
Fax — Non-specialty: 1-877-269-9916
Fax — Specialty: 1-866-249-6155
Do not submit forms to the Department of Insurance; submit to the patient’s health plan

Denial Risk

Statutory response timelines and deemed grant

Definitions

Prior authorization request — definition per policy

Definition"Prior authorization request" means a request for pre-approval from an insurer for a specified prescription or quantity of a prescription before the prescription is dispensed.

PurposeUsed by prescribing providers to initiate a prior authorization request with a commercial health insurance issuer regulated by the Illinois Department of Insurance.

Form requirementThe uniform electronic prior authorization form is required where a policy, certificate or contract requires prior authorization for prescription drug benefits (215 ILCS 5/364.3).

Prescribing provider — defined as in Section 364.3 of Illinois Insurance Code

Defined term"Prescribing provider" has the meaning ascribed in Section 364.3 of the Illinois Insurance Code [215 ILCS 5].

Role

Documentation Required

Required form fields and attestations

Complete all required form fields and attestations: indicate Standard or Expedited Review and, if Expedited, certify that a standard review period may seriously jeopardize the patient’s life, health, or ability to regain maximum function. Provide patient demographics, prescriber and pharmacy information, drug details (including diagnosis and ICD code), rationale, failed/contraindicated therapies (if applicable), and the prescribing provider’s attestation and signature.

Select Standard or Expedited Review and provide provider’s direct contact and initials if Expedited
Patient demographics and hospitalization status
Prescribing provider information (name, NPI, specialty, DEA if required, contact)
Pharmacy information
Requested drug details (name, strength, dosing, duration, diagnosis, Diagnosis ICD#)
Rationale for request and failed/contraindicated therapies
Prescribing provider attestation, signature, and date

Note

Coverage note and potential follow-up

A prior authorization approval on this form is not a guarantee of benefits or payment; coverage remains subject to the patient’s plan terms, eligibility, premium payment, limits, and exclusions. Insurers may request additional clinical information and follow-up, and submitting insufficient information can lead to extended review or an adverse determination.

Benefits remain subject to plan terms, eligibility, limits, exclusions, and payment of premiums
Insurers may require follow-up inquiries or additional information depending on the drug
Insufficient clinical information may extend review or result in adverse determination