Provider Portal

External UsersExternalLast updated: 2026-09-08

The Provider Portal is a public page your health plan publishes for prescribers. You do not need an account or a password to use it. Open the web address the plan gave you — it ends in /p/ followed by the plan’s short name.

If the address is mistyped or the plan has not published a portal, the page shows a short message saying the portal is not available. Check the address on your letter or the plan’s provider page.

Your plan may also give you a second, narrower address that ends in /formularies/ followed by a formulary’s short name. That one opens a single published formulary page rather than the full portal. See Opening a Published Formulary Page below — it is a read-only list of that formulary’s policies, with none of the prior authorization, data request, or appeal tabs.

What You See First

Across the top of the page you will see Provider Portal, the title Pharmacy Guidelines and Prior Authorization Management, and the health plan’s name or logo on the right so you can confirm you are on the correct plan’s portal.

The page is then split in two: clinical policies on the left, and the actions you can take on the right.

Reviewing Clinical Policies

The left side lists the policies the plan publishes under the heading Medical Pharmacy Policies. Two labelled groups at the top choose which set you are looking at:

Medical Benefit — the card reads Administered / Infused, for drugs given by a provider in an office, clinic, or infusion center.
Pharmacy Benefit — the card reads Self-Administered, for drugs the patient administers at home, filled through a specialty pharmacy.

Select a card to switch between the two lists. The selected card is outlined. Policies that apply to both benefits appear in both lists, so you will find the policy whichever card you start from.

Use Search by drug or brand name to narrow the list. As well as drug and brand names, the search also matches the policy name and the indication, so either will find what you are looking for. A count directly under the search box tells you how many policies match; if nothing matches, the list tells you so and you can clear the search box to start over.

Each entry shows the policy name, any category tags the plan applied, the drugs the policy covers, and the indication it applies to.

Where the plan has attached the policy document, the entry is a link with an open-in-new-window icon on the right. Selecting it opens the policy PDF in a new tab so you do not lose your place on the portal. Entries without that icon have no document published yet — the criteria are still shown to you when you start a request against them.

Opening a Published Formulary Page

Separately from the portal above, a plan can publish an individual formulary at its own public address. It looks like the portal address with two more parts on the end: /p/ and the plan’s short name, then /formularies/ and the formulary’s short name. Plan staff copy this address from the formulary’s details screen and send it to you.

This is a different page from the Provider Portal, and the difference matters:

What you can do	Provider Portal	Published formulary page
Address ends in	the plan’s short name	the plan’s short name, then `/formularies/` and the formulary’s short name
Policies listed	every policy the plan publishes	only the published policies in that one formulary
Benefit filters and search	Yes	No
Start a prior authorization, respond to a data request, or start an appeal	Yes	No

Like the portal, the formulary page needs no account or password.

What You See

The header reads Public Formulary with the plan’s name or logo beneath it. Below the header, the formulary’s name appears as the page title, followed by its description when the plan wrote one.

Under that, each published policy is shown as its own card with a PDF icon, the policy name, and a short summary when one is available.

While the page is still loading you see Loading formulary….

Viewing a Policy Document

Each card that has a document carries a View Document link with an open-in-new-window icon. Select it to open the policy PDF in a new tab so you keep your place on the formulary page.

Cards for policies with no document attached read Document unavailable instead. Nothing is missing on your end — the plan has not published a document for that policy yet.

If the Page Is Not Available

The page shows This formulary is not available. Check the address you were given. whenever the address does not lead to a published formulary. The message is the same in every case, so it will not tell you which part of the address is wrong. That message appears when:

the plan’s short name or the formulary’s short name is mistyped,
the plan has not published that formulary, or
the plan has taken the formulary page back offline.

Check the address against the letter or email you received, and contact the plan if it still does not open.

If the formulary is published but none of its policies are, the page loads normally and reads No policies are currently published for this formulary. The plan publishes each policy individually, so more may appear later.

Starting a Prior Authorization

The right side of the page has three tabs. Start Prior Authorization is the first and is selected when the page opens.

To begin, fill in all four fields:

Prescriber NPI — your 10-digit National Provider Identifier. If you enter something that is not 10 digits, a message appears under the field once you move away from it.
Patient Name — the patient’s first and last name.
Patient Date of Birth.
Member Number — the patient’s member or cardholder ID, as printed on their card.

Verify & Continue stays unavailable until all four are complete. Select it when you are ready.

If the details do not match a patient the plan already has on file, you will see a single message asking you to check the NPI, patient name, date of birth, and member number. The message is the same for every kind of mismatch, so it will not tell you which field was wrong. Re-check each value against the patient’s card and try again.

A note under the button reminds you that this page handles protected health information and that access is logged and monitored.

Confirming What Was Matched

When the details match, the tab replaces the form with Verification Complete and a summary of exactly what you submitted: patient name, date of birth, member number, and prescriber NPI. Nothing has been started yet — read the summary and choose:

Begin request opens the clinical form for that patient.
Edit details returns you to the four fields so you can correct a value and verify again.

Verifying again is safe; it simply replaces the previous match. Note that verification is only held while the tab is open — if you close or reload the page you will verify again from the start.

After You Begin the Request

Begin request takes you to the Clinical Data Collection screen. A breadcrumb at the top reads Verification › Clinical Data Collection; select Verification to go back to the portal home page.

A summary strip confirms the patient name, date of birth, member number, and prescriber NPI you submitted. Below it the screen is split: Coverage Criteria on the left, and the form you complete on the right.

Your session lasts about an hour and only covers the patient you verified. If you close the tab you will need to verify again.

Choosing a policy

Under Select a Guideline, choose the policy you are requesting against. The list is the same catalog shown on the portal home page. Where a policy names a specific indication, the indication appears next to the policy name so you can pick the right one.

Reading the Coverage Criteria panel

As soon as you choose a policy, the left panel lists only the conditions that still need supporting information. Conditions the plan already considers satisfied are not shown, and the panel does not display values from the patient’s record (age, labs, or diagnoses already on file).

A red cross means the information on file does not satisfy that condition yet.
A grey question mark means the plan cannot tell from what it has, so documentation is still worth attaching.

If nothing is listed, there are no outstanding automated conditions for this policy. You can still attach documentation and submit for review. This panel is a preview, not a decision — red or grey items do not stop you submitting. If the panel cannot be produced (for example the plan’s systems are briefly slow), it says the criteria are unavailable instead of implying that the policy is empty. You can select Retry, or attach the supporting documentation you have and submit without the preview.

Attaching documents

Under Clinical Information, select Browse files to attach chart notes, labs, or imaging. PDF, JPG, PNG, and TIFF files up to 25 MB each are accepted; attach as many as you need, one at a time.

Each file is listed once it uploads, and the plan begins reading it immediately. A clock icon means it is still being read, a check means it has been read, and a warning icon means it could not be read — if that happens, try attaching it again or continue without it. When a document finishes being read, the Coverage Criteria panel refreshes, so a condition that was listed as still needed may drop off.

You do not have to wait for documents to finish processing before submitting.

Telling the plan how to reach you

EHR Direct Address is optional. Enter a Direct Secure Messaging address if you would like the plan to send correspondence straight into your EHR. The address is saved when you submit the request, even if you never edit the fax number.

Below it, Fax Number on File shows the fax number 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 request and future correspondence with your NPI. Saving a fax number does not remove a Direct address you have entered, and vice versa.

Submitting

Select Submit for clinical review. There is no draft to save; submit when you are ready. Submitting attests that what you have provided is accurate and supported by the patient’s medical record.

The confirmation screen gives you a Case Reference — a six-character code. Write it down and quote it in any correspondence about this request.

The confirmation is a receipt, not a decision. Any documents you attached are still being read, and a reviewer follows up using the contact details on file, so you do not need to keep the page open or wait for an outcome on screen.

If you have already submitted a request for the same policy and patient and it is still open, the portal tells you so and gives you the existing case reference rather than starting a second request. Anything you attached is added to the open case.

Responding to a Data Request

If the plan has asked you for more clinical information on a case that is already open, choose the Data Request tab.

Enter the Case Reference Number — the six-character code printed on your letter — along with your Prescriber NPI and the Patient Date of Birth, then select Look Up Case.

When the case is found you stay on the portal. A green confirmation appears above the button reading Case located. Continue to upload your clinical documentation., and the button changes to Open Data Request. Select it when you are ready and the portal opens the response form for that case. The response form asks you to confirm the date of birth and NPI once more, then shows Information Still Needed on the left and Information Requested on the right under the title Data Request Response Form, where you either fill out the requested fields or attach medical records. Below your response you can enter a Direct EHR address and review or correct the fax number on file for your NPI. Prescriber Data Collection Form walks through that screen.

If nothing matches, you stay on the portal and see a message asking you to check the case reference, NPI, and date of birth.

Starting an Appeal

If a request was denied and you want to appeal, choose the Appeal tab. The tab only leads anywhere if your plan has appeals switched on.

Enter the Case Reference Number, your Prescriber NPI, the Patient Date of Birth, and the Member Number. All four are required, and all four are checked against the case before it opens. Enter the member number as it appears on the patient’s card; spaces, dashes, and capitalisation do not matter. Then choose an Appeal Type:

Standard (30 days)
Expedited (72 hours)

Select Start Appeal. As with a data request, the portal locates the case and opens it. After you confirm the date of birth and NPI, the page opens under the title Appeal Response Form in the two-column response layout — you are not asked again whether you want to appeal — and the turnaround you chose here is shown as a read-only chip on the appeal form. See Submitting an Appeal for the rest of the form, including the separate uploader for academic studies and clinical literature.

Starting the appeal here is what carries your choices forward. Opening the case any other way — from a link in a letter, for example — asks you how you want to proceed and lets you pick the turnaround on the appeal form itself. Only the appeal you start on this tab arrives with the turnaround already settled, so contact the health plan if you need to change it afterwards.

If the case cannot be found, you stay on the portal with a message asking you to check the case reference, NPI, date of birth, and member number. As on the prior authorization tab, the message is the same whichever of the four did not match, so it will not tell you which one to change — re-check each against the patient’s card and your letter. If the case is not one that can be appealed, you see its current status instead of the appeal form.

Finish the appeal in the same browser tab. If you close the tab between starting the appeal here and submitting it, reopen the case and the appeal form will ask you to choose the turnaround again.

If Something Does Not Work

“This portal is not available.” The address does not match a published portal. Confirm the address with the health plan.
The policy list does not load. Refresh the page. If it keeps failing, contact the plan.
A policy link opens a “not found” page. The plan has withdrawn or replaced that policy since the list loaded. Refresh the portal to see the current list.
“This formulary is not available.” The formulary address does not lead to a published formulary. Re-check both short names in the address against the letter or email you were sent, and contact the plan if it still does not open.
A formulary page says no policies are published. The formulary is published but its policies are not yet. Check back later or contact the plan.
A card reads “Document unavailable.” The plan has not attached a document to that policy. Contact the plan if you need a copy.
Verification keeps failing. The patient must already be known to the plan. Confirm the member number and date of birth exactly as they appear on the patient’s card, and confirm you are using the prescribing provider’s NPI. The same applies to the Appeal tab, which checks the member number as well.
The Coverage Criteria panel says the criteria are unavailable. Select Retry to load them again. You can still submit; attach the supporting documentation you have.
A document shows a warning icon. It could not be read. Try attaching it again, or submit without it and send it by fax quoting your case reference.
“We could not submit your request.” Nothing was submitted and no case reference was issued. Wait a moment and select Submit for clinical review again.