Prior Authorization & Notification Requirements and Referrals
2024
Authorization & Notification Requirements (PDF)
2023
Medical Services Authorization & Notification Requirements (PDF)
Mental Health and Substance Use Disorder Services Authorization & Notification Requirements (PDF)
Please see the Pharmacy page for information regarding Medical Injectable Drug Authorizations.
Medical Services
AIR/LTAC Admission Notification Form (PDF)
Durable Medical Equipment/Supply Prior Authorization Request Form (PDF)
General Prior Authorization Request Form (Not used for mental health services or medical drug authorization) (PDF)
Genetic Testing Prior Authorization Form (PDF)
Hospice Election Communications Form (PDF)
Pre-Determination Request Form (Not used for medical drug pre-determinations) (PDF)
Transplant Services Notification Form (PDF)
See the Medical Injectable Authorization Forms on the Pharmacy page.
InterQual® Medical Necessity Criteria
InterQual is a registered trademark of Optum, Inc.
Medical Necessity Criteria Request Form (PDF)
Reconstructive and Cosmetic Health Services Policy (PDF)
Medical necessity guidelines are available to assist in the determination of medical necessity for certain clinical procedures (procedure, therapy, diagnostic test, medical device, etc.) where coverage requires determination of medical necessity.
Utilization Management Criteria Memo (PDF)
Mental Health and Substance Use Disorder Services
Pharmacy and Drug Coverage Info
Find drug coverage for each Aspirus Health Plan Medicare Advantage plan and information to request exceptions or authorizations on our Pharmacy page. A formulary outlining the covered drugs and associated limitations, along with criteria used for prior authorizations is available:
2024 Formulary
2023 Formulary
Find medical injectable drug prior authorization information for Aspirus Health Plan Medicare Advantage plans and forms to request authorizations on our Pharmacy page.
Care Management Referrals
The Care Management Referral form is completed when you have a member/patient who you feel would benefit from care coordination services and is actively enrolled in an Aspirus Health Plan Medicare Advantage Plan.
Care Management Referral Form (PDF)
Disease Management Program & Referrals
The Disease Management Referral form is completed when you have a member/patient who you feel would benefit from these services and is actively enrolled in an Aspirus Health Plan Medicare Advantage Plan.
Disease Management Programs (PDF)
Disease Management Referral Form (PDF)
Delegates
Aspirus Health Plan works with delegated organizations to handle the following types of authorization.
Direct all authorization questions to Aspirus Health Plan’s delegate, Fulcrum Health, Inc. | 1-877-886-4941 (toll free)
Direct all authorization questions to Aspirus Health Plan’s delegate, Delta Dental 1-866-298-5520 (toll free) or 612-402-3950
Find medical injectable drug prior authorization information for Aspirus Health Plan Medicare Advantage plans and forms to request authorizations on our Pharmacy page.
Direct all authorization requests to Aspirus Health Plan’s delegate, Express Scripts, 1-877-558-7521 or by fax at 1-877-251-5896. Find more information on our Pharmacy page.