IRTS extension (more than 90 days) request

Complete this form when requesting an extension of IRTS services for Hennepin Health members beyond the initial 90 days. Include with this form:

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

The following timelines apply to this request:

Upon completion, print the form using the “View/print PDF” button and fax it to (612) 677-6222.

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

Provider contact information

Request date

Name of person completing form

Direct dial phone number

Extension

Fax number

Member name

Date of birth

PMI/MA number

Phone number

ICD-10 diagnosis codes & descriptions

Servicing clinic/agency/facility

Phone number

Address, including suite number

City

State

Zip code

NPI number

Place of service type/code

Complete the following questions

1. Admission date

2. List current mental health symptoms

3. Is this service helping the member become more self-sufficient as demonstrated by measurable progress?

Yes

Provide detailed information

4. List the reasons why the member requires an IRTS level of care beyond 90 days

Coding information *

HCPC code	Number of days requested	Start date	End date