UPPER PENINSULA HEALTH PLAN
REFERRAL AUTHORIZATION PROCESS

Verify:

• Eligibility
• Requested service is a covered benefit
• Requested service requires prior authorization or notification
• PCP approval if referral is from an authorized specialist

Request:

• Referral requests are to be done by the PCP
• An out of plan specialist with an authorized referral can request an extension, and/or an out of plan facility
• The forms are available on the website at www.uphp.com or from customer service. Choose the appropriate form:
• Clinical Services Prior-Authorization Request Form
   (Revised July 2007.)
• 4D - Request for Prior Authorization (pharmacy)
• DME/Medical Supply Request Form and Cover Sheet
   (Effective May 31, 2008.)
• Synagis Criteria and Prior Authorization Request
• Completed forms are sent by fax or by mail to the number/address on the form (Urgent requests may be phoned in)
• Pertinent clinical documentation should accompany the request

Authorization must be obtained before services are provided. Retrospective requests will not be reviewed.

Authorization does not guarantee payment. Benefit determinations are subject to diagnosis eligibility, member eligibility, and plan benefits at the time when a service is provided.