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Ghihmo

Prior Authorization Form for GHI HMO, GHI Medicare Choice
and GHI Family Health Plus PPO
Phone: GHI Medicare Choice (866) 557-7300 - FHP PPO and GHI HMO (877) 244-4466 Fax :GHI Medicare Choice: (866) 725-6603 Fax: FHP PPO and GHI HMO 877-508-2643
Please Note: All services requiring prior authorization for the products referenced above (other than for an emergency) must be approved in advance by a GHI or GHI HMO Medical Director or designee. Prior authorization is subject to all terms and conditions of the member’s contract and is only valid for eligible health plan members at the time of service. Please Print Legibly or Type:
PATIENT/MEMBER IDENTIFICATION
Workers Comp _ No Fault _ Other Insurance _ Is this a GHI Medicare Choice Member? _ Yes _ No REQUESTING PRIMARY CARE PROVIDER (OR OB/GYN) INFORMATION NPI Number: ________________________
REQUESTED SERVICE
_ Ambulatory Surgery: see Focused List for procedures that
_ Specialist Acting as Primary Care Coordinator _ Center of Excellence/Specialty Care Center (non-par) _ Chiropractic, PT, OT (see reverse side for details) _ Radiology (see reverse side for details ) _ Other (i.e. select services per Medical Policy. See Provider Manual and policies on www.ghi.com or contact GHI for copy) Provider Rendering Service if different from above: Facility where service is to be performed: (Full Name, Phone Number w/ area code required) Tax ID Number (required): ______________________
Tax ID Number (required): ______________________
If non-participating, indicate specialty: Address of Facility where service to be performed: Indications for Surgery/Procedure/Supply/Medication: (Attach Consult/diag., x-ray, progress report etc.)
ICD-9 CM Codes(s): (required)
Two surgeon (modifier 62) requested? Check one CPT-4 Billing Code(s):
(required)
Please note: urgent requests are those where a delay in treatment/service could seriously jeopardize the life or health of the member or
the member’s ability to regain maximum function or would subject the member to severe pain that cannot be adequately managed
without the care or treatment requested.
For Medicare Members Only: A request for expedited determination is when the enrollee or his/her physician believes that waiting
for a decision under the standard time frame could place the enrollee’s life, health or ability to regain maximum function in serious
jeopardy; and the enrollee believes that the Medicare Advantage organization should directly or arrange for service to be provided
(when the enrollee has not already received the services outside of the Medicare Advantage organization).
Required: If an urgent/expedited condition exists, you must provide detailed justification here:

Signature of Requesting Provider: Date:
Please refer to the GHI HMO or GHI Medicare Choice PPO Provider Manual for Medical Coverage Policies. Additional details furnished upon request by
calling GHI at (877) 508-2643. This authorization does not guarantee payment of benefits or verify eligibility. Payment of benefits is subject to all terms,
conditions, limitations, and exclusions of the member’s contract. Regardless of a determination, medical decisions regarding a course of treatment are solely
between the provider and his or her patient.
Revised 1/1/2008
See Reverse for Quick Reference To GHI/GHI HMO Authorizations GHI Medicare Choice: (866) 557-7300 FHP PPO and GHI HMO 24 hour phone: (877) 244-4466 QUICK REFERENCE REFERRAL AND PRIOR AUTHORIZATION REQUIREMENTS
GHI HMO, MEDICARE CHOICE PPO, AND GHI FAMILY HEALTH PLUS PPO
Important: This is an abbreviated list of the most common services requested and is intended as a quick reference tool only. For
complete information, refer to the GHI Medical Coverage policies. A list of policies may be found in the GHI HMO Provider
Manual or the GHI Medicare Choice PPO Provider Manual on GHI.com or may be requested by calling Customer Service at
(877) 244-4466.
TO LOCATE A PARTICPATING PROVIDER GO TO GHI.com.

Referral/Authorization Requirement
Service
Prior Authorization Needed
Referral Needed
No Authorization
Ambulance (non-emergent)
X (see coverage policy)
Ambulatory Surgery
X
For select procedures only
(See Focused Amb/Surg
Prior Auth Code List)
Bariatric Surgery/Lap Banding
X
Biofeedback X
Cardiac Rehabilitation
X
X
By provider of service after
Initial eval only
initial evaluation
Chiropractic Care
X
X
Contact Prism Health Network at
After initial 6 visits
(866) 284-2901
(after 8 for Medicare
Advantage)
Potentially Cosmetic Procedures
X
Diagnostic/Imaging – CT, MRI, MRA,
X
Nuclear Medicine, PET Scans, OB
CareCore National at
Ultrasounds in excess of 3
(800) 533-1206
Diagnostic/Imaging - routine
X
Durable Medical Equipment (DME)
X
In excess of $2000 ($500
Medicare Advantage)
Emergency Care
X
Erectile Dysfunction Treatment, supplies,
X
drugs
Experimental/Investigational X
Not covered under some
contracts
Hyperbaric Oxygen
X
Home Care/Home IV
X
Hospice X
Infertility Treatment
X
Not covered under some
contracts
Inpatient Care (hospital, rehabilitation,
X
skilled nursing facility)
Medications: growth hormone, Factor XIII,

X
IV, Algulcerase, Interferones, Cox2
Inhibitors, Retinoids, cosmetic meds, fertility
agents and meds for erectile dysfunction,
Amevive, Erythroid stimulants, Lamisil,
Provigil, Regranex, Raptiva, Revatio,
Synagis Xolair, Zyvox.
Note: List is subject to change.
Non-participating providers

X
Refer to GHI.com to locate a
par provider
Pain Management
X
Physical/Occupational Therapy
X
X
X
Contact Prism Health Network at
After first 6 (after first 20
For initial 6 visits
For Medicare
(866) 284-2901, Fax# 716-712-2817
Medicare Advantage)
Advantage
Contact GHI HMO for Medicare
Sleep Studies

X
Participating Specialist
X
Speech Therapy
X
Wireless Endoscopy
X
Behavioral Health/Substance Abuse
Call Magellan Behavioral Health Care at (877) 244-4466.
For Medicare Advantage and FHP PPO call Value Options at (877) 244-4466
Optometry – Routine Annual Eye Exams
Call Davis Vision at (800) 999-5431

The information contained in this grid should not be used as a substitute for the policies and procedures found in the Provider
Manual and if any information in this grid differs from the Provider Manual or the member contract, the Provider Manual or the
member contract shall control.
Rev 7/1/07

Source: http://www.drhasan.info/Forms%20Download/hmo_prior_auth2008-01-01.pdf

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