Prior Authorization Request Form for

Outpatient Services

Prior authorization is required forcertain services, even when being obtained from an in-network provider. Failure to submit the completed form to Health Tradition Health Plan may result in denial of services.

Please note: The following services have their own specific forms located at .

  • Autism
  • Bariatric surgery evaluation only (must be a benefit for the member)
  • Bone anchored hearing aid (BAHA)
  • Durable Medical Equipment (DME)
  • Hi-tech radiology - Care to Care Health Tradition Prior Authorization Fax Form
  • Intensive In-Home Therapy Services for BadgerCare Plus members
  • Kyphoplasty
  • Mental health/chemical dependency services out-of-network
  • Pharmacy, including Lansoprazole, Memantine, Celecoxib
  • Psychological testing

Use this form for any other services not noted above that require prior authorization.

  1. Complete all sections of the form. Failure to provide the requested information will delay the processing of your request. Any incomplete or illegible forms will be returned. If more space is needed, you may attach additional documentation to this form.
  2. Fax the completed form to the Utilization Management Department at 608-781-9654.
  3. After the Health Plan receives the request, reviews all necessary information, and determines medical necessity, a decision letter will be sent to the member and the requesting provider.

To verify member’s eligibility, benefits, and what services require prior authorization, please contact:

1-877-832-1823 (MMSI) – Premier, Premier Plus, Premier One, and 65Plus Plans

1-800-545-8499 - BadgerCare Plus Plans

/ Please complete form and fax to:

Health Tradition Health Plan UM Department

Fax Number: 608-781-9654
PRIOR AUTHORIZATION REQUEST FOR OUTPATIENT SERVICES

IMPORTANT: All fields are required. Incomplete forms will be returned and not reviewed. Submit this form along with clinic notes or letter of medical necessity and plan of care.

Member Information

 Premier  Premier Plus  Premier One  BadgerCare  Other ______

Patient Name:______DOB:______

Phone #:______Insurance I.D. #:______

Insured Address:______

Diagnosis Codes: ______AND Diagnosis Description: ______

Provider Information

Ordering Practitioner Name/Clinic: ______

Servicing Provider Name/Clinic: ______

Servicing Provider City/State: ______

Servicing Provider Phone#: ______Servicing Provider Fax#:______

Name of person completing form: ______Clinic/Facility Name: ______

Phone#: ______Fax#: ______

Type of servicebeing requested

Home health visits including RN, OT, PT, ST – specify # of visits per week and duration below

Home infusion – specify medication and duration below

Hospice services – specify duration below

Implantable infusion pumps

Implantable sacral nerve stimulation device

Negative pressure wound therapy

Orthognathic surgery

Panniculectomy

Positional plagiocephaly

Sleep study

Speech therapy (not related to an established diagnosis of Autism or in-home therapy)

Other______

Additional Information ______
______
______

______

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