Prior Approval

Prior approval (PA) is required for many DMA services. The preferred method to submit prior approval requests is online via the NCTracks Provider Portal.

However, providers can also submit some paper forms via mail or fax. The links below reference the latest PA forms for submission to NCTracks. This list is now the definitive source for DMA Prior Approval forms.

For a list of services that require prior approval, see the DMA policy specific to the services to be rendered.

For pharmacy PAs, refer to the Pharmacy Services page.

For additional information about how Prior Approval works in NCTracks, see the Prior Approval Fact Sheet on the Fact Sheet page of the Provider Portal.


Prior Approval Requests

The recommended method for submitting a Prior Approval request is to key it directly into the secure Provider Portal. If you must mail or fax a Prior Approval request, use the form below that pertains to the service being requested. See the DMA Clinical Coverage Policy Website for additional information. The below forms must be sent as the top page with any attachments behind it.

Prior Approval Attachments

The below forms should be sent in to accompany a Prior Approval Request. These forms will NOT create a Prior Approval request. They must be sent in with one of the forms listed above. If not, your Prior Approval request may be delayed or not received at all.

When either of the following forms are used, they need to be uploaded as attachments to the Prior Approval request that has been keyed into the secure NCTracks Provider Portal. These forms cannot be mailed or faxed and neither of these forms can be used to create a Prior Approval request.

Long Term Care FL2 Form (DMA372-124)

MPW Request for Prior Approval (DMA-0002)


Prior Approval Forms for Pharmacy

Pharmacy Services Drug Request Forms page