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 gray "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.