Outpatient Medical Services Prior Authorization Request Form

This form is for non-contracted providers. Contracted providers should submit authorization requests and check status online by logging in at hap.org and selecting Authorizations.

Please complete all fields below and include supporting clinical information (e.g., office visit notes, lab results, radiology results, etc.).

If you have any questions, call (313) 664-8950, option 1.

Please enter your email address for your registration confirmation email.

* are required fields

*Is this for a non contracted provider (choose one)? Yes No

This form is for non contracted provider’s only. If you are contracted, please fax request to 313-664-5916 or submit through Care Affiliate.

*What is the line of business for the patient's insurance? AHL ASO DSNP FED HAP HMO HAP POS MA MA PPO Medicare WRAP QHP UAW

This form is not for patients with Medicaid. All Medicaid requests will be processed by CareSource.

*Contact person name: *Contact person phone number: *Contact person fax number:

(Fax number to send completed authorization determination.)

Label *Email Confirm Email

Member Information

*HAP or HAP Empowered member ID number (11 digits): *Member name (first and last) *Member’s date of birth: *Member’s phone number:

Ordering provider information

*NPI: *Name (first and last): *Phone number: *Fax number: *Address:

Servicing provider information

For surgical procedures, list the physician providing the service.

Will you bill the claims with an individual doctor NPI? *Physician NPI: *Physician name (first and last): *Physician office phone number: *Physician office fax number: *Physician address:

Servicing facility information

For surgical procedures, list the facility providing the service.

Will you bill the claims with a facility/group NPI? *Facility NPI: *Facility name: *Facility office phone number: *Facility office fax number: *Facility address:

General authorization information

*Which setting will services be provided in (choose one)? Inpatient Outpatient *Start and end date of authorization request (example: 01-01-2017 to 06-01-2017): *Event classification (choose one): Standard pre-service Urgent pre-service Post service (for services already rendered AND the claim has NOT been denied)

PLEASE NOTE-If you received a denial on a submitted claim, please follow the HAP Provider Appeals process and do not submit this authorization request. Please fax provider appeals to (313) 664-5640 (on the fax coversheet please include “ATTENTION APPEALS”). Or call (313) 664-8950, option 2

*ICD 10 code(s):

Service/items needed (list CPT/HCPCS codes and quantity for each service in the corresponding box below).

*CPT/HCPCS: *Quantity: CPT/HCPCS: Quantity: CPT/HCPCS: Quantity: CPT/HCPCS: Quantity: CPT/HCPCS: Quantity: CPT/HCPCS: Quantity: Other comments: I agree to send all supporting clinical information, to the RMT@hap.org email.

Upon clicking the Submit button, the form contents will be submitted to HAP.

Supporting clinical information:

For all supporting clinical information, please attach any related files, list the name of the patient and their HAP ID in the body of the email, and send them to RMT@hap.org.

Resources

Resources

Have Medicare questions?