Prior authorization

Providers are required to verify member eligibility before submitting a request for authorization.

Prior authorization for pharmacy services

Some medications require prior authorization. (For injectable or intravenous medications provided in a clinic, office, or home setting, see the medical and behavioral health services section below.)

Pharmacy prior authorization requirements are embedded in the Medicaid list of covered drugs (Formulary) document below. Medications requiring authorization are designated by the initials PA within the special code column in the drug listing.

Medicaid list of covered drugs (Formulary) – effective 12/22/2022 (PDF)

List of covered drugs for SNBC members with Medicare coverage (Formulary) - effective 9/1/2021 (PDF)

Pharmacy authorization forms

Send forms:

• By encrypted email to HH.Pharmacy.PA@hennepin.us
• By secure fax to 612-321-3712

Prescription drug prior authorization form (PDF) - For a medication that requires prior authorization or is considered non-formulary.

Prescription drug reconsideration request 

Prior authorization for medical and behavioral health services

Some health care services given to our members require prior authorization. Providers are responsible to verify eligibility and benefits before providing services to members.

Prior authorization list for medical and behavioral health services (PDF) - Our prior authorization list outlines which services require prior authorization or notification to Hennepin Health. 

Standard service requests submitted on a pre-service or concurrent basis are reviewed and completed within 10 business days of receipt. If you submit a standard request for services that have ended (i.e., a post-service request), the review time is 30 calendar days. 

Urgent requests are reviewed and completed within 72 hours. Use an urgent request when a standard review time:

• Could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function.
• Would subject the member to severe pain that cannot be adequately managed without the care or treatment being requested, in the opinion of the prescribing provider.

Service authorization forms

Send forms via secure fax: Inpatient notifications: 612-288-2878 ǀ Service authorizations: 612-677-6222

• Behavioral health home (BHH) notification (PDF)
• Continuity of care (COC) - Out-of-network providers complete this form to continue services if they provided them prior to a member's eligibility with Hennepin Health. Services are reviewed for continuity of care guidelines and could be authorized up to 120 days from the member’s eligibility date depending upon individual member clinical circumstances.
• Clinical trial attestation (PDF) - Complete this required CMS form when you submit an authorization request for a qualifying clinical trial. Submit this form along with our service authorization request form and relevant medical records for the medical necessity review. 
• Inpatient admission notification - Inpatient facilities (e.g., acute hospitals or rehabilitation centers and long-term acute care hospitals) use this form to notify us of member admissions.
• IRTS extension - IRTS providers complete this form to request an extension of IRTS services beyond the initial 90-day treatment period.
• Medical referral for MRRP members - A "restricted" provider uses this form to refer a restricted member to a non-restricted provider.
• Nursing facility communication (DHS form)
• Partnered provider out-of-network referral - Partner providers complete this form to notify us of a referral to an out-of-network provider. Hennepin Health partner providers include Hennepin Healthcare and NorthPoint Health and Wellness Center.
• Service authorization request (SAR) - Use this form to request authorization for medical and behavioral health services
• Substitute health service request