Form Htum59 - Prior Authorization Request For Outpatient Services
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1
2Please complete form and fax to:
Health Tradition Health Plan UM Department
Fax Number: 608-781-9654
PRIOR AUTHORIZATION REQUEST FOR OUTPATIENT SERVICES
Member Information
Patient Name:__________________________________________________ DOB:__________________________
Phone #:_______________________________ Insurance I.D. #:_______________________________________
Insured Address:________________________________________________________________________________
Diagnosis Codes: __________________ AND Diagnosis Description: ____________________________________
Provider Information
Ordering Practitioner Name/Clinic: _________________________________________________________________
Servicing Provider Name/Clinic/Location:
_________________________________________________________
Servicing Provider Phone#: _______________________ Servicing Provider Fax#:___________________________
Name of person completing form and phone #: _______________________________________________________
for
Steps
Submission
1. Verify eligibility, benefits, and what services require prior authorization by contacting Customer Service at:
• 1-800-545-8499 - BadgerCare Plus Plans
• 1-877-832-1823 (Mayo Clinic Health Solutions) – Group, Individual, and Medicare Supplement
(65+)
2. Complete both pages of the request form. Any incomplete or illegible forms will be returned. If more space
is needed, attach additional documentation to the form.
3. Fax the completed form to the Utilization Management Department at 608-781-9654.
Upon completion of the review, Health Tradition Health Plan will send a decision letter to the member and the
requesting provider.
HTUM59 – Rev 06012016
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Parent category: Medical