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Item Last Modified
Universal Claim Forms (UCF) external link
Title Last Modified
Universal PA Request Form – All Others 10/07/2021

For telephonic prior authorization requests or inquiries regarding a prior authorization please call (800) 477-3071.

Please fax prior authorization requests to one of the following numbers —

Regular Fax Line:
Urgent Requests:
Nursing Facility:
Mental Health Drugs:
Denials and Appeals
  • Only a patient or family member can appeal a prior authorization denial
  • The member has 30 days from receipt of the denial letter to submit a written appeal to the address below:
    • Kentucky Department for Medicaid Services
      Division of Administration and Financial Management
      Administrative Services Branch, 6W-C
      275 East Main Street
      Frankfort, KY 40621-0001
  • The prescribing physician can attend the appeal hearing and testify on the patient’s behalf
Item Last Modified
340B Non-participation Notice Form 02/23/2022
340B Participation Notice Form 02/23/2022