MHK-Provider Portal

Request Medical Prior Authorizations

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Name:

Member ID:

Plan Type/Group ID#:

Date Of Birth:

Benefit String:

LOB:

Address:

IPA/MG:

Phone:

Effective:

Term:

Special Programs:

Case Manager:

Standard      
Expedited

YES      
NO
YES      
NO

Servicing and Facility Provider Information

Servicing and Facility Providers

Action Provider Name NPI# DEA# Speciality Network Address Fax Number Provider Type Provider Status id
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*Diagnosis (*Denotes required field)

ICD - Search Results

Action ICD Number Description ICD Type Status Primary Diagnosis
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*Procedure (*Denotes required field)

CPT/HCPCS - Search Results

Action CPT/HCPCS# Planned Procedure Quantity Unit Type Frequency Modifier 1 Modifier 2 Start End Status Primary Procedure
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Known Allergies

Allergies

Action Allergy Type Medication Specific Type Status Reaction/Observation Notes Date Reported
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Authorization Status:

Reason:



Decision:

Reference#:



Procedure Status:




This authorization is not a guarantee of payment. It is the provider's responsibility to check eligibility for each date of service and to follow current payment policies guidelines, Benefits for this service are subject to the provisions of the members plan and his/her eligibility on the dates of service.

Auth is not created.

Inquiry#:




Please upload additional documentation supporting your request

The request needs further clinical review. Please provide symptoms, lab results with dates and/or justification for initial or ongoing therapy or increase dose and if patient has any contraindications for the health plan/insurer preferred drug. Please provide any additional clinical information or comments pertinent to this request for coverage (e.g. formulary tier exceptions)or required under state and federal laws.

See below to upload documentation and add supporting notes related to the request.

Uploaded Documents

Action Document Name
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Notes

Notes

Action Note Text Date Note Type Id
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