Get Healthpartners Prior Authorization Request For In-network Benefits - Unitypoint Employer Group 2023-2025

Completing the HealthPartners Prior Authorization Request for In-Network Benefits is essential for obtaining necessary medical services not available within your network. This guide aims to provide clear, step-by-step instructions to assist you in accurately filling out the form online.

Follow the steps to successfully complete the authorization request form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the member information section, enter the member's first name, middle initial, HealthPartners ID number, and date of birth.
3. Fill in the requester information, including last name, first name of the individual completing the form, business name, street address, city, state, zip code, and contact information including phone and fax numbers.
4. Next, provide the ordering physician's information. Include the physician's first and last name, NPI, specialty, clinic name and address, and their contact information.
5. If applicable, include information for any out-of-network clinicians. Input their details similar to the previous step.
6. For the out-of-network facility, provide the facility name, address, and billing tax ID, along with contact information.
7. In the service information section, enter the primary and secondary diagnosis codes, descriptions, procedure codes, service descriptions, proposed date of service, and the number of units or visits requested.
8. You will be prompted to answer if waiting for standard review time may jeopardize the member's health. Clearly state 'yes' or 'no' and provide a clinical reason for urgency if applicable.
9. Indicate if care is available within the UnityPoint network, whether to refer the patient to the University of Iowa, and answer any preference-related questions regarding the request.
10. Summarize previous providers the patient has seen relating to the diagnosis, including relevant treatments and outcomes.
11. Consider the level of care needed and select the appropriate option before providing a clinical explanation detailing why the requested service can only be fulfilled by the out-of-network provider.
12. Review all information for accuracy, save changes, and then proceed to download, print, or share the completed authorization request form as necessary.

Complete your prior authorization request online for seamless access to your healthcare needs.