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Intensive Home Community Based Services


The following forms are for services requiring prior authorization. Please complete and submit the request before providing the service to a member. For information regarding the Idaho Medicaid Behavior Modification and Consultation Program, please refer to the Provider Express portal. More information on how to use and fillout the PDFs is available here. All in-network service requet forms are web-based forms. Follow the link and login, then the exact form can be selected to fill out.

A brief training video for the new streamlined prior authorization process is now available in Relias.  Providers will be required to submit using the electronic process starting on Oct. 1, 2023. Any questions can be directed to your regional provider relations advocate.

Service Request Forms for In-Network Providers*

Service Request Forms for Out-of-Network Providers*

Out-of-Network Services Request Form (instant access PDF form)

Other Forms*

Idaho Administrative Code ( IDAPA) defines Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Services as Medically necessary services for eligible Medicaid participants under 21 years of age. EPSDT services are health care, diagnostic service, treatment and other measures described in section 1905(a) of the Social Security Act (SSA) necessary to correct or ameliorate defects, physical and mental illness, and conditions discovered by the screening services as defined in Section 1905(r) of the SSA, whether or not such services are covered under the State Plan. Services authorized must be considered, safe, effective, and meet acceptable standards of medical practice, and shall require prior authorization. Services are not covered for cosmetic, convenience, or comfort reasons.

The EPSDT Service request form is used to request prior authorization for outpatient behavioral health services for a child under 21 years of age that are deemed medically necessary and are not covered by the Idaho Behavioral Health Plan. For additional information on EPSDT and instructions on how to request EPSDT services please see: Optum Idaho Provider Manual > Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Services.
Early Periodic Screening Diagnosis Treatment (EPSDT) Form (instant acccess PDF form)
Field Care Coordinator Referral Form (instant access PDF form)

*Please call the Optum Idaho Provider Line at (855) 202-0983 Option 1 for issues with accessing or submitting forms.

Provider Clinical Questions: (855) 202-0983  | Primary Care Provider Psychiatric Consult press option 1