Prescriber Data Collection Form

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This form is intended only for prescribers and providers who have received a request for clinical information as part of a prior authorization review. If you are not a prescriber responding to a specific request, this form is not for you.

Who Receives This Form

When a prior authorization requires additional clinical data, the requesting health plan sends a letter to the prescribing provider. That letter contains a unique link to this form. The link is specific to the patient and the request — it cannot be used for any other case.

Accessing the Form

Open the unique link from your letter in a web browser. You do not need to create an account or log in. The page carries the same Provider Portal header band as your plan’s public portal, titled Medical Pharmacy Prior Authorization, with your plan’s name or logo on the right once the case loads.

You can also reach the same form from your plan’s Provider Portal: choose the Data Request tab, enter the case reference from your letter along with your NPI and the patient’s date of birth, and select Look Up Case. See Provider Portal for details.

Step 1: Identity Verification

The first screen asks you to verify your identity before you can access the patient’s request:

  1. Enter the Patient Date of Birth using the date field.
  2. Enter Your NPI Number (your 10-digit National Provider Identifier).
  3. Select Verify Identity.

If the date of birth or NPI does not match what is on file, an error message will appear. Double-check the values on your letter and try again.

After You Verify

A breadcrumb at the top reads Identity Verification › Data Request Response (or Appeal Response when you are filing an appeal).

A summary strip confirms the patient name, the six-character case reference, your NPI, and the medication under review when one is on file. If your plan publishes a logo or name with the form, it appears in the portal header on the right.

The page title names the errand you are on: Data Request Response Form when the plan is waiting on additional clinical information, with an Additional information requested chip under it, or Appeal Response Form when you are filing an appeal.

The screen below the strip is split in two: Information Still Needed on the left, and Information Requested on the right.

Reading the Information Still Needed panel

The left panel lists everything the review is still waiting on, grouped into patient demographics, laboratory values and vital signs, medication history, diagnoses, and procedures. Lab entries show the LOINC code the plan is asking about.

This panel names the criteria only. It does not show what the patient’s record already contains, so nothing in it reveals clinical values back to you. If the panel says nothing is outstanding, anything you send is passed to the reviewer as supplemental information.

Step 2: Choose How to Provide Clinical Data

On the right, Information Requested asks how you would like to submit the clinical information:

  • Fill out the form — Enter demographics, observations, medications, diagnoses, and procedures manually in the online form.
  • Attach medical records — Upload a clinical document (PDF, Word, or an image); the system will automatically extract the relevant data and show you a review screen before submission.

Select the option that works best for you. The outstanding criteria stay visible on the left while you work, so you can check your entries against what was asked for.

Telling the plan how to reach you

When you opened this case from the Provider Portal, or when your verification step established a secure session for this case, an EHR Direct Address field and Fax Number on File appear below the information you are submitting.

Enter a Direct Secure Messaging address if you would like the plan to send correspondence straight into your EHR. The address is saved automatically when you submit the clinical form, even if you do not open the fax editor.

These fields never hold up your clinical response. If you leave them exactly as they were, or you have no fax number and no Direct address to give, nothing is saved and your submission goes through as normal. If the contact details you did enter cannot be saved, your clinical response is still submitted and a message appears in the contact section asking you to check those details and save them again.

The fax number shown is the one the plan associates with your NPI. If it is correct, leave it alone. If it is wrong or missing, select the pencil icon, type the correct number, and select Save — the plan will use it for this case and future correspondence with your NPI. Selecting Save with both fields empty tells you to enter a fax number or a Direct address first.

If you arrived from a letter link and no session was established, these fields do not appear; the plan replies using the contact details already held for your NPI.

Filling Out the Form

If you choose Fill out the form, a structured form opens with sections for the clinical information requested. Complete the required fields and select Submit when finished.

Attaching Medical Records

If you choose Attach medical records:

  1. Select Choose file (PDF, Word, images) and pick your document. Files up to 50 MB are supported.
  2. The system processes the document — this may take a moment. A progress indicator will display while processing is underway.
  3. Once extraction is complete, a review screen appears with the data pulled from your document pre-filled into the form. Review each field and correct anything that was not extracted accurately.
  4. Select Submit to send the reviewed data.

If there is a problem processing your file, you will see an error message with options to Back (return to the upload step) or Try again.

What Happens After Submission

Once you submit the form, you will see a confirmation message. The clinical data is sent directly to the reviewer handling the prior authorization. No further action is needed from you for this step.

If the authorization decision requires a follow-up (for example, if the request is denied), you may receive another letter with options to provide additional information or submit an appeal.

Current Authorization Status

Depending on the current state of the authorization, the form may display one of the following notices instead of the data entry screens:

Status shown What it means
Authorization Approved This case has already been approved. No further data is needed.
Authorization Not Approved The authorization was not approved. You will see options to provide additional clinical data or submit a formal appeal (if available).
Appeal Under Review An appeal is currently being reviewed. You will be notified of the outcome.
Appeal Not Approved The appeal was not approved. You may have options to provide additional clinical data or submit an external appeal (if available).