MSHO/MSC+ Benefit Exception Inquiry

Instructions: Use this inquiry form when requesting an exception to a service or item outside the standard benefit set or when the service plan will exceed the case mix budget cap. Be as specific as possible to avoid a return request for additional information.

Complete one Benefit Exception Inquiry form per service or item. All sections must be completed. Return via email at: hp_mshomsc_cc@HealthPartners.Com or fax at 952-883-9764. Requests for waivered services will not be considered without screening dates & notes.

Member & Care Coordinator Information Date of Request (MM/DD/YY): (If this is Day 1 or 14 – please fax in ASAP) HealthPartners Member ID: Member Last Name: Member First Name: DOB: (MM/DD/YY): Program: MSHO Rate Cell A MSHO Rate Cell B MSC+ Rate Cell A MSC+ Rate Cell B Entity Providing Care Coordination: Care Coordinator (CC) Name: CC Phone: CC Email: Primary Care Physician: Clinic Name: Clinic Phone: Case Mix & Cap (or attach current budget worksheet):
Service Information Item/Service for Consideration: Service Request Type: Ongoing Service Request New Service Request Authorization Expiration Date (MM/DD/YY): Service Provider Name: Tax ID: Phone #: Fax #: Amount of Units: Frequency: Duration of item: HPCP Code: Total Cost: Requested Start Date:
Service Information Continued Primary Diagnosis (include description and ICD-10 code(s): Rationale to support requested item/service: Alternative resources CC has researched/attempted: Quasi formal services: Informal services: Other: List current services member receives (or attach current budget worksheet with all services listed):
Additional Documentation Member’s waiver screening date (MM/DD/YY) (Date the member will be, or last was, screened for the waiver) Notes: (Requests for waivered services will not be considered without screening dates & notes.) Documents attached to support need (check all that apply): Current finding from HRA Physical/Occupational/Speech/Respiratory Therapy Notes Durable Medical Equipment (DME) Description of Item Physician Notes Other Note: A prescription from a physician is not sufficient documentation without supporting physician notes.
Outcome Service Approved Start Date (MM/DD/YY): End Date (MM/DD/YY): Service Not Approved Member in Agreement – No need to return form to HealthPartners Member in Disagreement – Return to HealthPartners for issuance of DTR
Date: Care Coordinator Signature Date: HealthPartners MSHO/MSC+ Supervisor Signature