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  • Ingham Health Plan Prior Authorization

    Authorization request will be processed within 48 hours (excluding weekends and holidays). For questions contact 866-291-8691
  • SERVICES MUST BE MEDICALLY NECESSARY
    ONLY OUTPATIENT SERVICES COVERED –

    INPATIENT SERVICES AND EMERGENCY DEPT SERVICES NOT COVERED

    *Chemotherapy services - Not Covered

    SERVICES THAT REQUIRE PRIOR AUTHORIZATION (PA) FOR PAYMENT

    SERVICES ADDITIONAL INFORMATION
    Infusion Services Limited benefit
    Injection Medications Limited benefit
    Genetic Testing  
    Physical or Occupational Therapy Max 20 visits per year
    Radiation Therapy  
    Reconstructive Surgeries  
    Skin Procedures and Surgeries  
    Vascular Surgeries/Treatment   
    Unclassified Procedures  Limited Benefit

     

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  • BEHAVIORAL HEALTH SERVICES REQUIRING PRIOR AUTHORIZATION (PA) FOR PAYMENT AFTER 15 VISITS BY A BEHAVIORAL HEALTH SPECIALIST ARE EXHAUSTED:

      Code Brief Description
    Diagnostic or Psychiatric Evaluation  90791 Diagnostic Evaluation by Psychiatrist
    90792

    Psychiatric Diagnostic Evaluation with medication services

    Therapy (Substance Use)  G0396 Alcohol/Substance abuse Intervention (15-30 min)
    G0397 Alcohol/Substance Abuse Intervention (>30 min)
    Therapy (Mental Illness)   90832 Psychotherapy with Pt (30 min)
    90834 Psychotherapy with Pt (45 min)
    90837 Psychotherapy with Pt (60 min)
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  • DISCLAIMER:

    • This health plan is not insurance. Plan benefits are limited.
    • Authorization is for specific CPT/HCPCS indicated.
    • Authorization is not a guarantee of payment.
    • Reimbursement for services rendered is subject to:-Member's coverage and eligibility on the date of service.- Service(s) rendered are performed within effective date range of authorization.
    • Providers must comply with Medicaid requirements.
    • Authorizations expire on Dec 31 of the calendar year in which service was authorized, unless otherwise indicated.

    If you have questions regarding this authorization, you may contact us at 1-866-291-8691 or www.ihpmi.org

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