Provider Referral Form – Request for Preauthorization

McLaren Health PLAN
Phone: (888) 327-0671
Medicaid and Healthy Michigan (810) 600-7959 HMO Commercial/ Community, POS Commercial/ Community, and Health Advantage (810) 600-7966

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

7/31/2021

Standard/Routine
(All non-urgent authorization requests are processed within 14 days of receipt.)






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.

MEMBER INFORMATION




REFERRING PROVIDER INFORMATION










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.




Rendering or Supplying Provider/Facility Information::













MEDICAL PHARMACY:
Supplying Provider/Facility Information:







INPATIENT:



OUTPATIENT:

















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.