1. General Administration


2. Medical Administration


3. Dental Administration


4. Medical Policy


5. Pharmacy

General Administration

• Claim Adjustment & Appeal Requests - online
• Claim Adjustment Request - Fax Sheet
• Claim Appeal Form - Fax Sheet
• Claim Attachment Submissions - online
• Claim Attachment Fax Form - Dental
• Claim Attachment Fax Form - Medical
• Claim Correspondence

Medical Administration

• HealthPartners Program Referral Form - for select Case Mgmt, Disease Mgmt and Wellness programs
• Chemical Health Authorization Request Form
• Chemical Health Continued Service Request form - Care beyond 21 days
• Continued Outpatient Treatment Request - for ongoing OP and In-Home Therapy Requests
• Eating Disorder Authorization Request
• ICSI Report
• In-Home Therapy Request - Initial Request ONLY
• Innovation Award Submission Document
• Medical Practice Guidelines
• MN Universal Outpatient Mental Health/Chemical Health Authorization (MUTP)
• Minnesota Uniform Practitioner Change Form
• Minnesota Uniform Initial Application
• Neuropsychological and Psychological Testing Request
• Never Event Reporting
• Out of Area Hospital Notification Form
• Pain Program Prior Authorization Form
• Provider Recommendation Form
• Self Reported Complaint Form
• Site Survey

Dental Administration

• Credentialing Application
• Dental Provider Change Notice
• Fee Schedule Form
• W-9 form for Tax Id Changes
• Prior Notification of Diabetes or Pregnancy Form

Medical Policy

• Acupuncture Review Form
• Acupuncture Brief Symptom Inventory
• Breast Pump Review Form
• Clinical Trials
• Continuous Glucose Monitor - DME Request Form
• CPM Review Form
• Durable Medical Equipment (DME) CLINIC Prior Authorization Form
• Durable Medical Equipment (DME) VENDOR Prior Authorization Form
• Enteral Nutrition (Formula) Review Form
• Epidural Steroid Injection Medical Review Form
• Habilitative Therapy (PT, OT, Speech) Review Form
• Hospital Bed Review Form
• Implantable Spinal Cord Stimulator (SCS) for Treatment of Neuropathic Pain Medical Review Form
• Knee Arthroscopy Review Form
• Lift Chair Review Form
• Medical Dental Procedure Review Form
• Neuromuscular Electrical Stimulator Review Form
• Oral Appliances for OSA - DME Review Form
• Out of Network Chiropractic Submittal form
• PCA Assessment Request
• PCA Change of Vendor Request
• Procedures Prior Authorization Form
• PT / OT Rehabilitation Review Form
• Radiofrequency Ablation Spine Review Form
• Radiofrequency Ablation Spine Review Form - HealthPartners Care
• Sacroiliac (SI) Injections to treat SI joint pain Medical Review Form
• Sclerotherapy Review Form
• Sleep Study, Unattended - Medical Review Form
• Specialty Mattress Gp I or Gp II Review Form
• Specialty Mattress Group III Review Form
• Spinal Fusion, Lumbar, Medical Review Form
• Spinal Fusion, Lumbar, Medical Review Form - Effective 1/1/12
• Spine Surgery Consult Visit Prior Authorization Form - Effective 1/1/12
• Synagis (RSV) Season Review Form
• Transplant Prior Notification Reveiw Form
• Weight Loss Surgery Referral Checklist
• Wheelchair Review Form

Pharmacy

• New Drug Request Form
• Prior Authorization / Exception Form
• Minnesota Uniform Prior Authorization and Formulary Exception Form
• Growth Hormone Statement of Medical Necessity Form