MSHO/MSC+ Service Authorization Request Form

Instructions: Complete one Service Authorization Request Form per service. All sections must be completed. Return via email at: hp_mshomsc_cc@HealthPartners.Com or fax to 952-853-8744.

Use when requesting an authorization for:

Customized Living Services including New, Retroactive, Renewal and Updates to Existing Authorizations

CDCS including new and any support plan changes impacting authorization

Elderly Waiver supports and services including specialized equipment and extended supplies

PMAP supplies and equipment requiring prior authorization*

Custodial skilled nurse or home health aide visits*

Independent Living Services for persons not qualifying under MSHO supplemental benefits

MSHO Supplemental Benefits

Check here if this request is an amendment of an existing Service Authorization (i.e. change in daily/monthly rate, frequency or provider)

For Medicare or PMAP covered services and/or supplies that require prior authorization, providers need to submit authorization requests to HealthPartners Quality and Utilization Management (QUI) department through HealthPartners provider portal.

Member Demographics HealthPartners Member ID: Member Last Name: Member First Name: DOB (MM/DD/YY): Product: MSHO MSC+ Start Date (MM/DD/YY): End Date (MM/DD/YY): ICD 10-Code: Dx:
Service Service: Service Code and Modifier: HCPC Code: Frequency: Daily Amount: Monthly Amount: Total Number of Units Approved for Authorization Period: Rate Per Unit (if applicable): Additional Notes (if applicable):
Payer Payer (EW/PMAP/HP Benefit): Provider Name: Provider Tax ID#: Provider Fax #: Provider Address: Provider Phone #:
Date: Care Coordinator Signature

Additional Information and Instructions:

HealthPartners offers MSHO/MSC+ members additional services beyond the routine benefit set. In order to implement one of these services there must be an assessed identified need and it must be part of the individualized care plan. For MSHO Supplemental Benefits with an * noted, specific diagnosis requirements must be met. Diagnosis can be found on Supplement Benefits form. In order to facilitate arranging for one of these services, complete a Benefit Exception Inquiry form and Service Authorization form and submit to HealthPartners via Right Fax. The costs of these services are not included in member’s cap.

Service	Unit	Code/Cost	Cost	Payer	Instructions
Foot Care (non-diabetic routine care)	Visit	T1003_UC	$49.00	HP Benefit	Exception to Benefit form required
SNV for foot care	Visit	T1030	$75.02	HP Benefit	Exception to Benefit form required
Independent Living Skills Worker Counseling for non MSHO Supp Benefit	15 minutes	H2032_TF	$15.56	HP Benefit	Exception to Benefit form required
Palliative Care	Visit	No Code	No Cost	HP Benefit
MSHO Supplemental Benefits Requiring Authorization
*Independent Living Skills Worker
Adult Day Care for persons with cognitive impairment
ADC Transportation for persons with cognitive impairment
Psychotherapy for caregivers of persons with cognitive impairment