Get Healthpartners Prior Authorization Request For In-network Benefits - Unitypoint Employer Group 2018-2025

Completing the HealthPartners Prior Authorization Request for In-Network Benefits can be straightforward when guided appropriately. This guide provides step-by-step instructions to help users navigate each section of the form with confidence.

Follow the steps to accurately complete the authorization request form.

1. Press the ‘Get Form’ button to access the form and open it in your document editor.
2. Begin by filling in the 'Patient Information' section. Include the patient’s full name, HealthPartners ID number, date of birth, and group number.
3. Answer the question about the availability of care in the UnityPoint Health or ACO specialty network. Indicate 'Yes' or 'No' based on the patient's situation.
4. If care is not available within the network, specify whether the University of Iowa can provide the necessary services. If 'Yes,' continue completing the form; if 'No,' provide a rationale.
5. Summarize the UnityPoint Health or ACO specialty providers the patient has seen related to the diagnosis. Include the names, specialties, dates, treatments received, and outcomes.
6. Indicate if the patient has previously seen the out-of-network provider and provide the date of the last visit. Ensure to attach any clinic visit notes pertinent to past visits.
7. In the 'Reason for Request' section, clearly explain why the services can only be provided by the out-of-network provider. Include any necessary details to substantiate the request.
8. Complete the 'Requester Information' section with your name, clinic or facility information, and date.
9. Fill out 'Ordering Provider Information' by entering the physician's name, phone number, NPI number, specialty, clinic or facility details, and fax number.
10. Provide the 'Out of Network Provider Information' as well as the 'Out of Network Facility Information' (if applicable), including names, NPI numbers, specialties, and contact details.
11. Finish the 'Service Information' section by specifying the proposed date of service, level of care needed, diagnosis/ICD-10 code, CPT code(s), and a brief description of the service.
12. After completing all sections, ensure all clinical documentation supporting the request is attached. Save the document, and then you may download, print, or share the completed form as needed.

Complete your HealthPartners Prior Authorization Request online today and ensure all required documentation is included for timely processing.