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Starting May 12, 2024, State Fiscal Year Limits will begin, and the Service Authorization process will open.

Service Authorization Request Forms

Service authorizations are required for all services after participant state fiscal year limits have been exhausted. Providers are encouraged to use the forms located on this webpage as form versions may change.

Provider SFY Limit Verification Form/Process

Select the PDF fillable form, complete the information for the request, submit via secure email to

Timeframe for secure response from Optum:

  • Same day prior to 4:00PM
  • After 4:00PM, next business day
  • If after 4:00PM on Friday, weekend or holiday, next business day

Service Authorization Online Submissions

*Please ensure is a safe approved email in order to receive your verification code to re-enter a Service Authorization form.

Service Authorization Fillable Forms

To submit Service Authorization forms via fax, please send to: 1-844-881-3753.

Retrospective Review

Appeals Form