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Utilization Review Agent (URA) Forms

Utilization Review Agent (URA) Forms
TDI Form Number Description File FormatLanguage
LHL005
URA Application Form
Application to apply for URA Certification, renew a URA Certification or update a URA Certification
PDF English
NOFR001
Prior Authorization of Health Care Services
PDF English
NOFR002
Prior Authorization of Prescription Drugs
PDF English
SN009
Sample URA Adverse Determination Notice, Health
PDF English
SN010
Sample URA Adverse Determination Notice, Specialty Health
PDF English
SN011
Sample URA Adverse Determination Notice, Workers Comp Net
PDF English
SN012
Sample URA Adverse Determination Notice, Workers Comp Non-Network
PDF English

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