Ingham Health Plan Prior Authorization Request Form

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

Status of Authorization

Authorization Number

Date Authorization Processed

Date

Approved START date of services

Approved Start Date

Approved END Date of Services

Date

Comments

Processed By:

DISCLAIMER

- This health plan is not insurance.  Plan benefits are limited.&#13;&#10;- Authorization is for specific CPT/HCPCS indicated.&#13;&#10;- Authorization is not a guarantee of payment.  &#13;&#10;- Reimbursement for services rendered is subject to:&#13;&#10;- Member's coverage and eligibility on the date of service.&#13;&#10;- Service(s) rendered are performed within effective date range of authorization.&#13;&#10;- Providers must comply with Medicaid requirements.&#13;&#10;- Authorizations expire on Dec 31 of the calendar year in which service was authorized, unless otherwise indicated.&#13;&#10;&#13;&#10;- If you have questions regarding this authorization, you may contact us at 1-866-291-8691 or www.ihpmi.org

Member Name

First NameLast Name

Member DOB

Date

Member HPMS ID (numbers only)

Member Address (Must live in Ingham County, MI)

Street Address

Street Address Line 2

CityState

Zip Code

Office Contact/Person Submitting Authorization Request

NameOffice Name

Phone Number*

Fax*

Authorization Type

Requesting Provider

Servicing Provider

Name

Physician NPI

Tax ID Number

Service Location

Address for Service

Street Address

Street Address Line 2

CityState

Zip Code

Facility Name (if applicable)

Auth Class:

Sub-Class (Office):

Sub-Class (Outpatient):

Sub-Class (Equipment & Supplies):

Diagnosis Information

	Diagnosis Code	Diagnosis Description
Primary
Secondary
Other

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

	Quantity	CPT Code	Description	FOR IHP USE ONLY
1
2
3
4
5
6
7
8
9
10
11
12

Date of Procedure or Service:

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.

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*