Authorization for Phrenic Nerve Procedure
Requirements and form fields for providers to request prior authorization from HealthPartners for phrenic nerve–related procedures; applies to providers submitting authorization requests for members covered by HealthPartners.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial authorization submission
Authorization will be considered when the completed authorization form includes the clinical details listed below:
Fax completed forms to (952)853-8713 or contact Utilization Management for questions; incomplete forms will be returned.
Only submit procedure codes that require prior authorization. The form explicitly states: "Only include codes requiring authorization; other codes will not be addressed." Do not list codes that do not need authorization on this form.
Incomplete authorization forms will be returned. Submit a fully completed form along with supporting clinical documentation. Administrative errors such as an incorrect billing tax ID may cause claim rejection, so verify all facility and billing identifiers before submission.
For questions or to check status, contact Utilization Management per the form instructions and fax the completed form to the number provided. The form notes that clinical information is required to support medical necessity but does not itself state final coverage determinations.
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