Thank you for your interest in submitting a pre-certification request via web-form. At this time, the web-form is only available on tablets, laptops, and desktops.

Prior to submitting a request for precertification, please call the Provider Services or Precertification phone number on your patient's member ID card or visit Access Patient Benefits to determine where to send your precertification request and to review your patient's plan description for a full list of services requiring precertification.

To avoid delays, please confirm that HPI is the UM vendor prior to completing this form. To do this, please check the back of the members ID card.

The data from this website is received daily during our regular business hours, 8:00 AM to 5:00 PM EST. When the form has been successfully submitted, you will receive a confirmation reference number (this is not an authorization number).

Not sure if your service requires precertification? Check here.
   

Insurance Information
Insurance Company Name
Group Name / ID
Precert Type
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IMPORTANT: ICDs/CPTs must be added one at a time. Please click to Add to add an entry.
Once completed, click Save.
Diagnoses
Diagnosis 
Add
No Diagnoses have been added
Procedures
Procedure 
Procedure Date 
Add
No Procedures have been added
DME Cost (Monthly rental or purchase price)
Infusions, Injections, Specialty Drug (Cost per dose)
Service Start Date
v
Service End Date
v
Member PPO Network
Is this Primary Insurance
v
If no, who is Primary Insurance Carrier
Patient Information
Member ID
Last Name
First Name
Date of Birth
v
Gender
v
Address
City
State/Province
Zip/Postal Code
Phone
E-Mail
Insured Information
Member ID
Last Name
First Name
Date of Birth
v
Gender
v
Address
City
State/Province
Zip/Postal Code
Phone
E-Mail
Physician
EIN / Tax ID
NPI
Last Name
First Name
Specialty
Is Physician In Network
v
Address
City
State/Province
Zip/Postal Code
Phone
Fax
E-Mail
Facility
EIN / Tax ID
NPI
Facility/Agency Name
Is Facility/Agency In Network
v
Address
City
State/Province
Zip/Postal Code
Phone
UR Contact Name
UR Phone
UR Fax
Submitter Information
Name
Phone
Fax
E-Mail
Relationship to Patient
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Notes (Reason for Precertification/Referral)
Submission of this data to Health Plans Inc. does not verify eligibility, benefits, or coverage.
Send Precert Request