Preauthorization

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Get approval before receiving certain healthcare services. Check your Evidence of Coverage for a list of services that require preauthorization.

Use the electronic form below to submit your preauthorization request Or you may download and submit a hard copy form by mail to the address below.

UM Department Capital Blue Cross, Po Box 773731 Harrisburg PA 17177-3731

Required fields are noted with an asterisk *.

Provider Information
* Provider Name
* Street Address
Street Address Line 2
* City	* State	* Zip Code
* Phone Number	* Contact name at provider office
* Expected Date of Service	* Requested Service
CPT code	Diagnosis Code

Subscriber Information
* Subscriber's ID Number (as it appears on your ID card)
* First Name	Middle Initial	* Last Name
* Date of Birth
* Primary Phone Number	Other Phone Number	Email Address
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Updated January 1, 2025

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