Preauthorization Form

Attention Medicaid DME providers. Effective 2/1/2023, authorization will be required for the DME items affected by bulletin MMP 22-40. A list of specific items is located in MDHHS bulletins MSA 20-14, MSA 20-25, and MSA 20-32.

Provider Preauthorization Forms

McLaren Health Plan
Medicare Preauthorization Form
Phone: (888) 327-0671
Medicaid and Healthy Michigan (810) 600-7959 HMO Commercial/ Community, POS Commercial/ Community, and Health Advantage (810) 600-7966
McLaren Medicare (833) 358-2404

Service Codes Requiring Preauthorization

Genetic Testing Preauthorization Requirements
For Medicaid Members: Authorization requests for genetic and molecular testing submitted more than 30 days from the specimen collection date/date of service will not be approved. Specimen processing should not be completed until after the authorization request has been approved.

Printable Provider Authorization Form

Note: Fields marked with an * indicates required field

Request Date: *	3/25/2023
Type of Care: * Please select only one option.	InpatientOutpatientMedical Pharmacy
Standard/Routine (All non-urgent authorization requests are processed within 14 days of receipt.)
Member Service or Plan: * Please select only one option. If you are submitting an urgent Pharmacy request, an urgent CSHCS/Healthy Michigan/Medicaid request, an urgent McLaren Health Advantage, or urgent McLaren Health Plan Community request, select the “Urgent” radio button only. This applies to all lines of business. If requesting Routine Medical Pharmacy services, select the “Pharmacy” radio button only. This applies to all lines of business. For all other routine authorization requests, only select the radio button for the applicable line of business.	Urgent Pharmacy CSHCS/Healthy Michigan/Medicaid Health Advantage McLaren Health Plan Community

URGENT:
By selecting urgent, I certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within 72 hours to avoid complications and unnecessary suffering or severe pain. Please provide information on urgency.
Name of Provider Certifying: *

Rendering or Supplying Provider/Facility Information::
MEMBER INFORMATION
Member ID: *
Date of Birth (xx/xx/xx): *
Member First Name: *
Member Last Name: *
REFERRING PROVIDER INFORMATION
Specialty: *
Provider First Name: *
Provider Last Name: *
Provider Address: *
Office Contact: *
Office Email: *
Phone: xxx-xxx-xxxx: *
Fax: xxx xxx-xxxx: *
Medical Necessity Documentation attached: NOTE: File names for attachments must NOT contain special characters or spaces (dashes are allowed). Ex. file-smith.pdf Please fax medical necessity documentation exceeding a total of 35 MB in size to 810-600-7959.


Did you upload medical necessity documentation in the question above? *	Yes No
Specialty:*
Provider First Name:*
Provider Last Name:*
Billing NPI: *
Address:*
Office Contact: *
Phone: xxx-xxx-xxxx: *
Fax: xxx-xxx-xxxx: *
Facility:*
Billing NPI: *
Address: *
Phone: xxx-xxx-xxxx: *
Fax: xxx-xxx-xxxx: *

MEDICAL PHARMACY: Supplying Provider/Facility Information:
ICD- 10 Diagnosis Codes: *
HCPCS/CPT Codes: *
Medication Name: *
Treatment Start Date: *
Treatment End Date: *
Dosage: *
Frequency: *

INPATIENT:
ICD- 10 Diagnosis Codes: *
HCPCS/CPT Codes: *
Date of Service: *

OUTPATIENT:
Authorization Type: *	Auditory and Oral Procedures Behavioral Health Cosmetic Procedures - Medical Necessity review required to determine cosmetic vs. reconstructive DME Genetic Testing - All genetic testing codes require review and preauthorization Home Care Hospice Care Outpatient Therapies Neurostimulators Other Out of Network
ICD- 10 Diagnosis Codes: *
HCPCS/CPT Codes: *
Date of Appointment: *
Certification Period (if applicable): *
Number of Visits: *

Comments:
This referral is not a guarantee of payment. Please contact McLaren Health Plan to verify eligibility and covered benefits. All information, including any attachments are confidential and intended solely for the use of the intended recipient(s). All information is privileged or otherwise protected from disclosure by applicable law. Any authorized disclosure, dissemination, use or reproduction is strictly prohibited. If you have received this in error, please notify the sender immediately and destroy the information. IF YOU WOULD LIKE A COPY OF THIS REFERRAL FORM, YOU MUST PRINT IT (AFTER THE FIELDS ARE FILLED OUT). GO THE MENU BAR SELECT FILE THEN PRINT. ONCE HITTING SUBMIT, YOU WILL NOT BE ABLE TO OBTAIN A COPY OF THIS FORM.

Comments:

This referral is not a guarantee of payment. Please contact McLaren Health Plan to verify eligibility and covered benefits.
All information, including any attachments are confidential and intended solely for the use of the intended recipient(s).
All information is privileged or otherwise protected from disclosure by applicable law. Any authorized disclosure, dissemination, use or reproduction is strictly prohibited.
If you have received this in error, please notify the sender immediately and destroy the information.
IF YOU WOULD LIKE A COPY OF THIS REFERRAL FORM, YOU MUST PRINT IT (AFTER THE FIELDS ARE FILLED OUT). GO THE MENU BAR SELECT FILE THEN PRINT. ONCE HITTING SUBMIT, YOU WILL NOT BE ABLE TO OBTAIN A COPY OF THIS FORM.