Ingham Health Plan Prior Authorization Request Form

Ingham Health Plan Prior Authorization

Authorization request will be processed within 48 hours (excluding weekends and holidays). For questions contact 866-291-8691

ALL PROCEDURES/TESTS REQUIRE PRIOR AUTHORIZATION EXCEPT
OFFICE VISITS, AND ROUTINE DIAGNOSTIC OUTPATIENT LAB AND
RADIOLOGY SERVICES

SERVICES MUST BE MEDICALLY NECESSARY
ONLY OUTPATIENT SERVICES COVERED – NO INPATIENT SERVICES
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
Ophthalmologic exams and testing	Medically necessary – no vision services
Physical Therapy	12 visits per year, add visits with PA
Outpatient Surgeries
Radiation Therapy
Genetic testing
Reconstruction Surgery
Skin Procedures
Sleep Study
Vein Treatments & Surgery
Any service that could be considered cosmetic or not medically necessary
Unclassified procedure codes
Behavioral Health Continued Coverage	When individual has continued need after exhausting the 15 visits of the limited coverage benefits and attempts have been made to refer the individual to other public resources

Diagnosis Information

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
Diagnostic or Psychiatric Evaluation	90792	Psychiatric Diagnostic Evaluation with medication services
Therapy (Substance Use)	G0396	Alcohol/Substance abuse Intervention (15-30 min)
Therapy (Substance Use)	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)

Services Information

Date of Procedure or Service:

Month Day Year
Date
Additional Information (clinical notes for medical necessity can be added here or attached below)
Describe attempts to refer the individual to other community resources including Community Mental Health Services and response to referral: *
Attach Clinical Notes for Medical Necessity if applicable

Browse Files
If attaching more than one file, max file size is 100MB for EACH file. Cancel of
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
Please verify that you are human *
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