Call Member Services at 1-800-250-8427 with questions.
- Member Request for Coverage Exception
- The Member Request for Coverage Exception form is used for adults age 21 and older.
- See Rule 7104 of the Medicaid Covered Services Rules (7100 – 7700) for more information about Requests for Coverage Exception.
- To request coverage for members under age 21, a Medicaid enrolled provider should submit a prior authorization request. Prior authorization forms can be found on the Clinical Forms and Prior Authorization Forms webpage.
See section 5.2.1 of the Vermont Medicaid General Billing and Forms Manual for more information on EPSDT services.
- The Member Request for Coverage Exception form is used for adults age 21 and older.