Prior Authorization

HAP CareSource™ MI Health Link (Medicare-Medicaid Plan) evaluates prior authorization requests based on medical necessity, medical appropriateness, and benefit limits.

Services That Require Prior Authorization

Please refer to the Procedure Code Lookup Tool to check whether a service requires prior authorization. All services that require prior authorization from HAP CareSource MI Health Link should be authorized before the service is delivered. HAP CareSource MI Health Link is not able to pay claims for services in which prior authorization is required, but not obtained by the provider.

HAP CareSource MI Health Link does not require referrals to see an in-network specialist. The specialist may require a referral from the member’s PCP. Some services and procedures require prior authorization. Referrals and prior authorizations must be obtained prior to services being rendered. 

Prior Authorization Procedures

Urgent requests should be marked urgent. Urgent requests will be accepted when the member or their physician believes waiting for a decision under the standard time frame could place the member’s life, health or ability to regain maximum function in serious jeopardy. Referrals and prior authorization for services should be made to in-network providers whenever possible. Contracted providers can be found in our online Provider Directory.

The HAP CareSource Provider Portal is the preferred and faster method to request prior authorization for health care services. You get immediate approval or pend status and can also check pending claim status. For issues or questions with portal login, please contact provider services at 1-833-230-2159. For additional information or questions about HAP CareSource MI Health Link benefits, please visit the Navigate Provider Manual or contact Provider Services.

Alternate methods include phone, fax or mail.

Phone: 1-833-230-2159
Fax: 844-633-0399

Mail:
CareSource
P.O. Box 1307
Dayton, OH 45401-1307

Written prior authorization requests should be submitted on the Navigate Medical Prior Authorization Request Form.

Non-Participating Providers

Prior authorization must be obtained before sending patients to nonparticipating providers, with the following exceptions:

Emergency Services

All in-patient services require prior authorization. Please call 1-833-230-2159 to obtain prior authorization for emergency admissions. Outpatient emergency services do not require prior authorization.

Prior authorization is not required for coverage of post-stabilization services when these services are provided in any emergency department or for services in an observation setting by a participating provider.

To request prior authorization for observation services as a non-participating provider or to request authorization for an inpatient admission, please call 1-833-230-2159 and follow the appropriate menu prompts. During regular business hours, your call will be answered by our Medical Management department.

Please call 1-833-230-2159 for any questions related to post-stabilization services.

Advanced Imaging Prior Authorization

Ordering physicians must obtain prior authorization for the following outpatient, non-emergent diagnostic imaging procedures:

  • MRI/MRAs
  • CT/CTA scans
  • PET scans