CurrentHealthPartnersPolicy N/A
Medical-Dental Procedures - Facility-General Anesthesia review
This document is an authorization request form and instructions for submitting prior authorization for facility/general anesthesia related to medical-dental procedures to HealthPartners Utilization Management. It defines required submission fields, contact/fax numbers, and notes that only codes requiring authorization should be included.
Policy Summary
PayerHealthPartners
PolicyMedical-Dental Procedures - Facility-General Anesthesia review
Policy CodePolicy N/A
Change TypeAdministrative form/update
Effective Date
Next Review Date
Key ActionProviders must fax completed forms to (952)853-8713 or call UM at (952)883-6333 and submit supporting clinical documentation; only include procedure codes requiring authorization.
SourceLink
POLICY UPDATE CHANGES
No material clinical/coverage changes.
Auth formDocument type
0Material change
952-883-6333Contact UM
Authorization form — facility / general anesthesia (medical-dental)
This is the HealthPartners authorization request form for facility/general anesthesia used when medical-dental procedures require prior authorization. It collects member, requester, ordering and procedural provider, and facility and procedure details to support Utilization Management review.