Martin’s Point Health Care AUTHORIZATION REQUEST FORM GUIDELINES

PREAUTHORIZATION REQUESTS (PRE-SERVICE)

For Martin’s Point Generations Advantage and US Family Health Plan: • Not required for emergency care• Should be submitted at least two weeks prior to the date of service or facility admission• If the servicing provider is not part of the Martin’s Point network, submit this form with a letter of medical

necessity (including clinical documentation) explaining why the service(s) can only be provided by this specialist.• For mental health/substance abuse services call BHCP at 1-888-812-7335. • For drug preauthorization, visit www.martinspoint.org/For-Providers/Pharmacy. • For outpatient therapy (PT, OT, ST, SLP). Please use our “Outpatient Therapy Preauthorization Request Form”

(www.martinspoint.org/For-Providers/Preauthorizations). • For more information, visit www.martinspoint.org/For-Providers/Preauthorizations.

RETROSPECTIVE AUTHORIZATION REQUESTS (POST-SERVICE)

US Family Health Plan: We will review retro-authorization requests for all qualified care, before or after claim submission. There are no limiting circumstances. Participating and non-participating providers may use this form. Determinations will be made within 30 calendar days of the date of form receipt.

Generations Advantage: We will review retro-authorization requests only under the following circumstances. Please read the complete definitions at www.martinspoint.org/For-Providers/Preauthorizations before submitting this form.

• Urgent/Emergent: Applies when waiting for preauthorization could seriously jeopardize the life or health of themember, or the member’s ability to regain maximum function. Or, would subject the member to severe pain.

• Unable to Know: Applies when the provider did not have, and was unable to obtain, the patient’s insuranceinformation pre-service (i.e., unresponsive patient delivered to an emergency room).

• Not Enough Time: Applies when the patient requires immediate or very near-term medical services (typically relatedto a service already being performed). For example, during a procedure, the provider identifies an acute need forhospital admission or, the procedure that evolves into a different/additional procedure which is performedimmediately or scheduled for the same day.

Please do not submit this form unless your situation meets one of these criteria. If it does, please submit this form with documentation that supports the “Urgent/Emergent,” “Unable to Know” or “Not Enough Time” exception. We will first assess the criteria for coverage and then for medical necessity.

• Participating providers seeking retro-authorization for a Generations Advantage member must file a claim for thatservice, wait for claim denial, and then submit this Authorization Form. Determinations will be made within 14calendar days of the date of form receipt.

• Non-participating providers seeking retro-authorization for a Generations Advantage member must file a claim forthat service, wait for claim denial and then initiate the claim appeal process athttps://medicare.martinspoint.org/Member-Toolkit/Grievances-and-Appeals. Determinations will be made within 60calendar days of the date of appeal receipt.

Form submission instructions:

• All fields are required. Incomplete forms cannot be processed. Please include supporting clinical documentation.• For outpatient authorization requests, please fax the completed form to 1-207-828-7865.• For inpatient authorization requests, please fax the completed form to 1-207-828-7857.• Or, call 1-888-339-7982, 8 am to 4:30 pm, weekdays for inpatient or outpatient authorization requests.• Please do not resubmit preauthorization requests unless you are specifically requested to do so by Martin’s Point.• To check the status of a request visit www.martinspoint.org/For-Providers/Preauthorizations or call 1-888-339-

7982. • Authorization requests and approvals are not a guarantee of payment. Revised January 2016

MEMBER

LastName: FirstName:

DOB: HealthPlan: USFamilyHealthPlanGenerationsAdvantage

Policy#: Today’sDate:

REQUESTING PROVIDER

LastName: FirstName:

ProviderType:PCPSpecialistFacility

ContactName: ContactEmail:

ContactPhone: ContactFax:

SERVICING PROVIDER—IstheservicingproviderorfacilitypartoftheMartin’sPointnetwork? YesNo

LastName: FirstName:

ProviderNPI#: Specialty:

PracticeName:

PracticeNPI#: PracticeTaxID#:

PhysicalAddress:

MailingAddress(ifdifferentfromphysicaladdress):

BillingAddress(ifdifferentfromphysical/mailingaddress):

Phone: Fax:

SERVICING FACILITY

Name:

NPI#: TaxID#:

PhysicalAddress:

MailingAddress(ifdifferentfromphysicaladdress):

BillingAddress(ifdifferentfromphysical/mailingaddress):

Phone: Fax:

REQUESTED SERVICEIsthisacontinuationofservice?YesNo Isthisachangeindateofservice?YesNo

InpatientMedicalAdmission

InpatientSurgicalAdmission

OutpatientSurgical/Medical

OfficeVisit/Consult

OfficeProcedure

DurableMedicalEquipment

MedicalSupplies

MedicalNutritionTherapy/Counseling

Cardiac/PulmonaryRehab

AudiologyTesting/Therapy

WoundCare

PainManagement

Oncology(ChemoorRadiation)

Hospice

Other(pleasedescribe):

ICDDiagnosisCodes:

CPT/HCPCCodes(pleaseindicateleftside/rightsideorboth):

AnticipatedDateofService: NumberofVisitsRequested:

InpatientPreopDay?YesNo(Ifyes,pleaseprovidemedicalnecessitydocumentation.)

Martin’sPointHealthCare AUTHORIZATIONREQUESTFORM

Preauthorization/Pre-service RetroAuthorization/Post-serviceIf post-service please include the Martin's Point Claim #: