Submit Prospect Support Tickets

Submit your Prospect-related claim or authorization request online to skip hold times and get a quicker response through our secure form.

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Type of Request *

Claims
Routine Authorizations/Referrals
STAT Authorizations/Referrals
Eligibility

STAT Authorization/Referral – Emergency and life threatening: A referral due to potential morbidity, mortality, or serious condition involved that requires a treatment plan or approval. The turnaround time (TAT) for STAT requests is 72 hours to ensure timely review and response.

Routine Authorization/Referral – New routine authorization will need to be submitted through Aerial Care. The turnaround time (TAT) for routine requests is 5 business days to ensure timely review and response.

Claims – New Claims need to be submitted through Office Ally The turnaround time (TAT) for claims is 5 business days to ensure timely review and response. If you would like to immediately check your claim status, please use the following link: https://provider-portal.astranahealth.com/prospect-claim-status

Eligibility – Eligibility Online Web Form replaces phone calls for eligibility requests. Urgent requests have a 1-hour TAT; routine requests have a 24-hour TAT.

Claims Category *

For immediate claim status updates, use: https://provider-portal.astranahealth.com/prospect-claim-status

PMS Claim Number (If Known)

Member ID *

Member Name *

First

Last

Date of Birth (MM/DD/YYYY) *

Claim Date of Service (MM/DD/YYYY) *

Total Billed *

Billing Provider TIN *

Billing Provider Name *

Provider Callback Number *

Extension (If Applicable)

Email *

Message

Attachments

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Authorization Category *

Member Name *

First

Last

Member ID *

Date of Birth (MM/DD/YYYY) *

Referring Provider Name *

First

Last

Requested Provider Name *

First

Last

Specialty *

Date submitted (MM/DD/YYYY) *

Submitted by *

Referral/Authorization Number *

Provider Callback Number *

Extension (If Applicable)

Email *

Message

IPA Name *

Member Name *

First

Last

Member ID *

Health Plan Name *

Date of Birth (MM/DD/YYYY) *

Member Phone Number *

Referring Provider Name *

First

Last

Referring Provider Speciality *

Please specify if the referring provider is PCP, or specialist office. If specialist, please include specialty

Requested Provider Name *

First

Last

Specialty *

Date submitted (MM/DD/YYYY) *

Submitted By (Provider Staff Name) *

Place of Service *

CPT Code *

Diagnosis/ICD10 Code *

Provider Callback Number *

Extension (If Applicable)

Email *

Message *

Attachments *

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Member Name *

First

Last

Member ID *

IPA *

Member Health Plan *

Plan Plan (Provider

Member DOB *

Effective Date *

PCP *

Submitted By:

Phone Number *

Email Address *

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