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Routine Request, Motions, and Prior Authorization Response
Any denial other than a motion will be automatically appealed to the appropriate Internal Affairs Court.
Person Requesting
*
Nature of Request
*
After our initial review, we have made the following decision.
*
A
Approval - Unconditional
B
Approval - Conditional
C
Denied without prejudice (may amend and refile)
D
Denied with prejudice (may not refile)
E
Requires a Prior Authorization Review
F
Appealed without Decision to Internal Affairs
Conditions of Approval
*
Effective Date
*
Expiration Date
Submit