Request Authorization

Helpful phone numbers for assistance with authorization requests:

  • Provider Inquiry Number: (888) 732-7364
  • Health Management Number: (888) 339-7982
  • Behavioral Health Care Program (BHCP): (888) 812-7335
  • Generations Advantage Pharmacy Phone: (855) 344-0930
  • US Family Health Plan Pharmacy Fax: (207) 828-7816
Check Status of Prior Authorization

Instructions

Prior Authorization Instructions (Pre-Service)

For Martin's Point Generations Advantage and US Family Health Plan

  • Not Required for emergency care
  • Should be submitted at least 14 calendar days prior to the date of service or facility admission
  • For drug prior authorization, please visit our Pharmacy page
  • For more information, please visit our Authorizations page

Retrospective Authorization Instructions (Post-Service)

For US Family Health Plan

We will review retrospective authorization requests for all qualified care, before or after claim submission. Participating and nonparticipating providers may use this form. Determinations will be made within 30 calendar days of the date of form receipt.

For Generations Advantage

We will review retrospective authorization requests ONLY under the following circumstances. Please read the complete definitions at the Provider Manual

Utilization Management page before submitting this form.

  • Urgent/Emergent: Applies when waiting for preauthorization could seriously jeopardize the life or health of the member, or the member’s ability to regain maximum function. Or, would subject the member to severe pain.
  • Unable to Know: Applies when the provider did not have, and was unable to obtain, the patient's insurance information preservice (i.e., unresponsive patient delivered to an emergency room).
  • Not Enough Time: Applies when the patient requires immediate or very near-term medical services (typically related to a service already being performed). For example, during a procedure, the provider identifies an acute need for hospital admission, or the procedure evolves into a different/additional procedure which is performed immediately or scheduled for the same day.
    Please do not submit this form unless your situation meets one of these criteria. If it does, please submit this form with documentation that supports the "Urgent/Emergent," "Unable to Know," or "Not Enough Time" exception. We will first assess the criteria for coverage and then for medical necessity.
  • Participating providers seeking retrospective authorization for a Generations Advantage member must file a claim for that service, wait for claim denial, and then submit an Authorization Dispute Form found in the Forms and Documents section.
  • Nonparticipating providers seeking retrospective authorization for a Generations Advantage member must file a claim for that service, wait for claim denial, and then initiate the claim appeal process on the Grievances and Appeals page. Determinations will be made within 60 calendar days of the date of appeal receipt.

Out of Network

If the servicing provider is not part of the Martin's Point Generations Advantage or US Family Health Plan network, a letter of medical necessity and supporting clinical documentation from a clinically appropriate specialist must be submitted to support that the member’s condition and/or treatment cannot be provided within the network.