Authorization Submission Form

This form is intended for providers outside of Mass General Brigham Health Plan provider network. Use this form for medical authorization requests managed by Mass General Brigham Health Plan. For services managed through a vendor partner, please contact the appropriate vendor.

Fields marked with are required.

Inpatient Authorization Instructions Please follow the step-by-step instructions in the Inpatient Authorization User Guide. Admission
Home Health Care Authorization Instructions Please follow the step-by-step instructions in the Home Health Care Authorization User Guide. For hospice care, please refer to the Hospice Authorization User Guide. Each discipline must be submitted separately. For example: If you are requesting both Home PT and Home Skilled Nursing, you must enter a separate authorization for each. Home Care
Outpatient Authorization Instructions Please follow the step-by-step instructions in the Outpatient Authorization User Guide. For Surgical, the facility and the surgeon must both be entered in the Servicing Provider field. For Chiropractic, Oral Surgery and Transplant, enter the individual in the servicing provider field. If the individual provider is associated with more than one group, be sure to choose the correct provider option to ensure claims payment. For DME requests the servicing provider must be the DME provider. Outpatient Service
Speciality Referral Instructions Please follow the step-by-step instructions in the Specialist Referral User Guide. If you need to add additional visits to an existing referral Open existing referral in the provider portal and click on "Revise Request" at the top. If you need a referral for dates outside of an existing referral Enter a new request below. Ensure your date span is different than an existing referral. Specialist Service

Select Authorization/Referral Type:
Requested Service

Member Section
Date of Birth:			Member ID:
Requesting Provider
Provider NPI			Provider Name
Address 1
Address 2

City	State	Zip
Contact Name	Contact Phone
Servicing Provider
Provider NPI	Provider Name
Address 1
Address 2

City			State			Zip
Contact Name			Contact Phone

Servicing Surgeon
Provider NPI			Provider Name
Address 1
Address 2

City			State			Zip
Contact Name			Contact Phone

Codes
Diagnosis	Search

Procedure Code

Start Date
End Date

Remarks (limited to 255 characters)

	Cancel

Description:
File:

	Cancel

Authorization Submission Form

Inpatient Authorization Instructions

Admission

Home Health Care Authorization Instructions

Home Care

Outpatient Authorization Instructions

Outpatient Service

Speciality Referral Instructions

Specialist Service

Member Section

Requesting Provider

Servicing Provider

Servicing Surgeon

Codes

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