Standardized Prior Authorization Request Form
PLEASE COMPLETE ALL INFORMATION BELOW. INCOMPLETE SUBMISSIONS MAY BE RETURNED UNPROCESSED.
HPI — Corporate Headquarters • PO Box 5199 • Westborough, MA 01581 • 800-532-7575 • 508-756-1382 (fax)
StandardPriorAuthRequest_020221
Please direct any questions regarding this form to the plan to which you submit your request for claim review.
The Standardized Prior Authorization Form is not intended to replace payer-specific prior authorization procedures, policies and documentation
requirements. For payer-specific policies, please reference the payer-specific websites.
Health Plan:
Health Plan Fax#:
Date Form Completed and Faxed (required):
HPI
508-756-1382
Service Type Requiring Authorization
1,2,3
(check all that apply)
Ambulatory/Outpatient Services
☐Surgery/Procedure (SDC)
☐Infusion or Oncology Drugs
Ancillary
☐Acupuncture
☐Chiropractic
☐IVF / ART
☐Non-Participating Specialist
Dental
☐Adjunctive Dental Services
☐Endodontics
☐Maxillofacial Prosthetics
☐Oral Surgery
☐Restorative
Durable Medical Equipment
☐Prosthetic Device
☐Purchase
☐Renal Supplies
☐Rental
Home Health/Hospice
☐Home Health (please indicate:)
☐SN ☐OT ☐HHA
☐PT ☐ST ☐MSW
☐Hospice
☐Infusion Therapy
☐Respite Care
Inpatient Care/Observation
☐Acute Medical/Surgical
☐Long-Term Acute Care
☐Acute Rehab
☐Skilled Nursing Facility
☐Observation
Medication
Buy or bill or submit via the Medical benefit: ☐Yes ☐No
Purchase or submit via Pharmacy benefit: ☐Yes ☐No
Cost per dose is Greater than $2,000: ☐Yes ☐No
Nutrition/Counseling
☐Counseling
☐Enteral Nutrition
☐Infant Formula
☐Total Parenteral Nutrition
Outpatient Therapy
☐Occupational Therapy
☐Physical Therapy
☐Pulmonary/Cardiac Rehab
☐Speech Therapy
Transportation
☐Non-Emergent Ground
☐Non-Emergent Air
Imaging
☐Non-Urgent ☐Urgent/Emergent*
*Precert required for claim payment, clinical
not required. Must submit form within 2
business days of the urgent imaging service.
Provider Information
*Required field
*Provider Name/Address:
☐Referring Provider ☐Treating Provider
*Tax ID#:
*Phone#:
*Fax#:
*Servicing Facility Name/Address: *Tax ID#: *Phone#: *Fax#:
*Phone#:
Email/Fax#:
Member Information
*Required field
*Patient Name:
*Insurance Plan Member ID#:
*Gender:
Male Female
*Date of Birth:
Address:
Phone#:
If other insurance:
Insurance Company:
Policy#:
Diagnosis/Planned Procedure Information
*Required field
*Procedure/Service Description:
*Diagnosis Description:
CPT/HCPCS Codes:
ICD-10 Codes:
Quantity Requested:
☐
Hours
☐
Days
☐
Months
☐
Visits
☐
Dosage
*Service Start Date: Surgery Date (if applicable): *Service End Date:
1
Please attach plan specific templates that are required for supporting clinical documentation.
2
Not all services listed will be covered by the benefits in a member’s health plan product.
3
This form does not replace payer-specific prior authorization requirements.
Clear Form