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Please select urgency of request: *

Member Information

Member Last Name: * Member First Name: *
Member ID: * Member DOB: *
Diagnosis: * ICD-10: *

Provider/Facility/Agency/DME Provider Requesting Authorization

Provider Last Name: * Provider First Name: *


Facility/Agency/DME Provider Name: *
NPI: *
Phone: * FAX: *
Primary Office Contact Name: *

Type of Request: *  

- General Prior Authorization -

Referred To:
Provider Last Name: * Provider First Name: *
(or)      Facility/Agency/DME Provider Name: *
Specialty: *
Facility: *
Address: *
City: *     State: *     Zip: *
Phone: *     Fax: *
HCPCS Codes (if applicable):
Appointment Date (if known):
Type of Service Requested: *  
Are these services Out of Network? *  
- Hospital Admission Notification -

Type of Admission: *
Facility Name: *
Admission Date: *
Reason for Admission: *
Please fax discharge date to 906-225-9269
- LTC Admission Notification -

Facility Name: *
Admission Date: *
- SNF/ Swing Bed Notification -

Facility Name: *
Admission Date: *
Type of Skilled Service (Select all that apply) *
Frequency of Therapy/Treatment: *  
Is patient participating in therapy
Barriers to Discharge (Select all that apply)
Is long term care placement anticipated? *
Estimated Discharge Date:
Actual Discharge Date:
- Home Health Prior Authorization -

NOTE: UPHP does not require prior authorization for the initial 60 days of home health care for
in-network home health providers.

Home Health Agency Name: *
Ordering Provider
Provider Last Name: * Provider First Name: *
Home Health Admit Date: *
Type of Service Requested (Select all that apply) *
Reason for Home Health: *
Is member homebound? *  
If yes, homebound due to: *  
Assistive Devices Used: *  
Estimated Duration of Home Health Needs: *  
- Durable Medical Equipment (DME) Prior Authorization -

DME Provider Name: *
Phone: *   Fax: *
Initial or Expected Date of Delivery: *

Reason for Prior Authorization (Select all that apply) *  

- Genetic and Molecular Testing Prior Authorization -

Lab Name: *
Lab Address: *
CPT Codes: *
UPHP Staff Use Only
Approved ______      Denied* ______      Partial Denial* ______      Withdrawn ______
*Denial letter will be sent to member and requesting provider with appeal rights.
Decision Date: _________________________      UPHP Staff Name: _________________________________
Authorization #: _____________________________________________
Authorization Start Date: _________________________      End Date: _________________________
# Office Visits: ___________    # Outpatient Services: ___________    # Units: ___________
Home Health: ___________
Inpatient Admission: ___________    Observation Admission: ___________    Global Authorization*: ___________
*Global Authorization: An authorization for any specialty, for as many office visits or outpatient services as needed. Does not include inpatient admissions or observation admissions.
Comments: _________________________________________________________________________________


Authorization does not guarantee payment. All authorized items and services are subject to review for medical necessity, member eligibility, member plan benefits, and provider eligibility for payment at the time of service. All providers must be enrolled in the Michigan Community Health Automated Medicaid Processing System (CHAMPS) in order to receive payment for all Medicaid programs.