PRE-AUTHORIZATION/REFERRAL …
pre-authorization/referral authorization request form inpatient/acute ___ observation ___ rehab ___ ltac ___ snf ___ admission date: _____ office: ⃞ outpatient: ⃞ home health: ⃞ dme: ⃞ inpatient: ⃞ scheduled date of service requested: _____
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Imperial Health Holdings Medical Group
imperialhealthholdings.com4 | P a g e SECTION 1. INTRODUCTION 1.1 Imperial Health Holdings Medical Group (IHHMG) IMPERIAL HEALTH HOLDINGS MEDICAL GROUP (IHHMG) Imperial Health Holdings Medical Group (IHHMG) is a health care service plan with a …
PRECERTIFICATION/REFERRAL REQUEST FORM
imperialhealthholdings.comJul 23, 2019 · This referral is valid only for services authorized on this form. This Referral Form does not guarantee payment by IHHMG or the Health Plan. Responsibility for payment shall be subject to member eligibility, benefit limitations, and the interpretation of benefits under applicable subrogation and coordination of benefits rules.
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