prior authorization for procedures and surgeryhp/... · 2020. 12. 15. · only include codes...

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Prior Authorization for Procedures and Surgery Fax completed forms to (952)853-8713. Call Utilization Management (UM) at (952)883-6333 with questions. Incomplete forms will be returned. Submit clinical documentation to support your request. 20-913603-913616 (9/20) © 2020 HealthPartners DOB Fax** Phone* Fax** NPI ❑ Office ❑ Outpatient ❑ Inpatient Phone* Fax** NPI Fax** Your business state Your business zip Last Name Facility name Clinic state Clinic zip Clinic state Clinic zip Facility state Facility zip *Confidential voicemail required **For outcome notification Billing tax ID (claim may be rejected if incorrect) Facility City Facility street address Phone* Member information First Name Requester information Form completed by: First Name Your business name Your business street address Your business city Phone* Last Name Provider last name Provider last name Ordering provider information Provider first name Specialty Clinic name Clinic street address Clinic city Clinic tax ID (claim may be rejected if incorrect) Email Procedural provider information Provider first name Specialty Clinic name Clinic street address Clinic city Clinic tax ID (claim may be rejected if incorrect) Email Facility site for procedure or surgery MI HealthPartners ID #

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Page 1: Prior Authorization for Procedures and Surgeryhp/... · 2020. 12. 15. · Only include codes requiring prior authorization; other codes will not be addressed. Primary diagnosis code

Prior Authorization for Procedures and Surgery Fax completed forms to (952)853-8713. Call Utilization Management (UM) at (952)883-6333 with questions. Incomplete forms will be returned. Submit clinical documentation to support your request.

20-913603-913616 (9/20) © 2020 HealthPartners

DOB

Fax**

Phone* Fax**

NPI

❑ Office ❑ Outpatient ❑ Inpatient

Phone* Fax**

NPI

Fax**

Your business state Your business zip

Last Name

Facility name

Clinic state Clinic zip

Clinic state Clinic zip

Facility state Facility zip

*Confidential voicemail required**For outcome notification

Billing tax ID (claim may be rejected if incorrect)

Facility CityFacility street address

Phone*

Member information First Name

Requester information Form completed by: First Name

Your business name

Your business street address

Your business city

Phone*

Last Name

Provider last name

Provider last name

Ordering provider information Provider first name Specialty Clinic name Clinic street address Clinic cityClinic tax ID (claim may be rejected if incorrect) Email

Procedural provider information Provider first name Specialty Clinic name Clinic street address Clinic cityClinic tax ID (claim may be rejected if incorrect) Email

Facility site for procedure or surgery

MIHealthPartners ID #

Page 2: Prior Authorization for Procedures and Surgeryhp/... · 2020. 12. 15. · Only include codes requiring prior authorization; other codes will not be addressed. Primary diagnosis code

20-913603-913616 (9/20) © 2020 HealthPartners

Will waiting the standard review time seriously jeopardize member’s health, life or ability to regain maximum functioning? yes no

Procedure code(s)

Procedure(s) or surgery description

Proposed date of procedure

Procedure or surgery Only include codes requiring prior authorization; other codes will not be addressed

Primary diagnosis code

Secondary diagnosis code

Updated last on 04/27/2021 Member Name HealthPartners ID#

Description

Description

Clinical reason for urgency (not scheduling issues)

or TBD

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