MediGold requires prior authorization on select services through our utilization management team. Please review the MediGold Prior Authorization List for codes requiring prior authorization.
- Download a Prior Authorization Request Form from our website at MediGold.com/For-Providers/Tools-and-Resources/Forms.
- Complete the form with the required information and any additional documentation to support the request.
- Fax completed form to MediGold at 614-234-8672.
- MediGold will review the request by following our Prior Authorization Decision-Making Process.
- You will receive a decision as expeditiously as the member's health condition requires.
- Standard Request: Goal is three to five business days. Our average is 3.2 business days.
- Expedited Request: A decision will be rendered within 72 hours of receipt.
Prior Authorization Decision-Making Process
Utilization review nurses determine medical necessity following the hierarchy of these guidelines:
Oncology Prior Authorization Presentation
Oncology Prior Authorization Webinar
Oncology Required Documentation
- Treatment requested (CPT/HCPCS code).
- Diagnosis or clinical indication.
- Clinical documentation to support medical need:
- Eastern Cooperative Oncology Group Score (ECOG) or Karnofsky Performance Status (KPS).
- Genetic findings or tumor markers.
- Most recent lab results (bilirubin, PSA, CBC, CEA, AFP levels).
- Prior imaging studies (CT, MRI/PET).
- Office notes.
Additional medical oncology requirements:
- Cycle start date, length and the number of cycles requested.
- Medication doses per treatment.
- Cancer stage/performance status.
- Prior surgical intervention.
Additional therapeutic radiation therapy:
- Type of radiation therapy.
- Cancer staging.
- Prior radiation treatment.
- The number of fractions requested.
- Dose per fraction.
Our vendor agreement with HealthHelp ended on 5-27-18. Below are frequently asked questions we have received
- What if a provider submitted a PA to HealthHelp on 5-27?
At the end of day on 5-27, HealthHelp will hand off all open submissions to MediGold.
- What if a provider submits a request to HealthHelp on 5-28 and beyond?
The portal will be shut down and inaccessible.
If a provider submits a fax request, HealthHelp will respond with provider directions.
- Will MediGold still retro authorize oncology services within 72 hours of date of service?
• Retro authorization submissions will continue through 5-27.
• As of 5-28, no retro authorization submissions will be accepted.
If you have additional questions, please see the MediGold Oncology Prior Authorization Webinar or call us 8 a.m. – 4 p.m., Monday – Friday, at 614-546-3120 or 1-800-240-3870 (TTY 711).