Gundersen Lutheran Health Plan utilizes and adopts nationally developed medical policies; commercially recognized criteria sets; regionally developed medical coverage policies; and locally produced specialty medical coverage policies. Additionally, the Health Plan involves appropriate practitioners in development, adoption and review of criteria and medical coverage policies. All criteria are available upon request by contacting the Health Plan Medical Management Department. A written copy can be sent electronically, by mail, or directly communicated via the telephone.

• Procedures and Services Requiring Prior Authorization (PA Grid) 
  • Prior Authorization Request Form
  • Prior Authorization Form for Part B Therapies (Provided in a Skilled Nursing Facility) Extending Beyond 30 Visits 

General Forms

• Referral Authorization
• Criteria Used for Durable Medical Equipment (DME)
• Wheelchair Rental
• Functional Mobility Assessment 
• Provider/Practitioner Datasheet

Senior Preferred Forms

• Hospital Preadmission Denial Notice
• Detailed Notice of Discharge  
• Notice of Medicare Non-coverage: Home Health 
• Notice of Medicare Non-coverage: Skilled Nursing Facility
• Notice of Denial of Medical Coverage: Skilled Nursing Facility Admission 
  • What is this Notice?
• Notice of Denial of Medical Coverage: Hospital Observation Level of Care
  • What is this Notice?
• Notice of Denial of Medical Coverage: Swing Bed
• Senior Preferred Personal Physician Change in Status 

Pharmacy Forms
If you have questions about the drug prior authorization process, please review the provider manual, or the drug prior authorization process overview.

• Employer Group Drug Prior Authorization
• Senior Preferred Part D Prior Authorization Request
• Pharmacy and Therapeutic Committee: Formulary Request for Review

Completed forms should be sent to:

Gundersen Lutheran Health Plan
1836 South Avenue, Mail Stop: NCA2-01
La Crosse, WI 54601 or faxed to the number on the form.