Continuity of Care Request

This form should be completed by Out-of-Network (OON) providers seeking authorization for continued services for members newly eligible with Hennepin Health. OON providers should complete this form for Hennepin Health members, attach relevant clinical documentation, print using the 'View/Print PDF' button at the bottom of the form, and fax to 612-677-6222.

Note: all DME and home care services, including home infusion, require signed order from provider (MD, APRN, PA, or CNS).

Incomplete forms may result in denial of requested services for lack of information.

The following turnaround times apply to this request:

Retro Requests: 30 calendar days Current/Standard Requests: 10 business days Urgent Requests: 72 hours

Questions? Call Hennepin Health Provider Services at 612-596-1036, press option 2.

Provider Representative Contact Information

Request date

Name of person completing form

Direct dial phone number

Extension

Fax number

Member Information

Member name

Date of birth

PMI / MA number

Phone number

Date of enrollment

ICD-10 Diagnosis codes & descriptions

Requesting/Ordering Practitioner Information

Requesting/Ordering Provider

Phone number

Clinic name

Clinic phone number

Clinic address, including Suite #

City

State

ZIP code

Requesting/Ordering Practictioner NPI number

Specialty

Servicing Provider Information

Servicing Clinic/Agency/Facility

Phone number

Address, including Suite #

City

State

ZIP Code

NPI number

Place of Service Type/Code

List up to 3 dates of service with this provider in the past 12 months prior to enrollment with Hennepin Health for the member's diagnosis :

Date

If request is for prenatal care, provide the expected date of delivery

Continuity of Care services are authorized for up to 120 days beginning on date of enrollment with Hennepin Health.

CPT/HCPC

Start date

End date

Dollar amount

Number of Units

Comments

All required fields must be entered prior to clicking on 'View/Print PDF' to create a PDF. The PDF may automatically download depending on your browser's settings.

Please fax the printed form to: 612-677-6222