When to Call For Inpatient Hospital Prior Approval

You, a family member, physician, hospital, or other health care provider should notify us about any inpatient, emergency, or non-emergency hospitalization. 

• Contact us at 1-866-841-6572.
• For a scheduled inpatient hospital admission, please call HIRSP at least 3 business days in advance
• For an emergency inpatient hospitalization, please call HIRSP within 2 business days after admission

Please have the following information ready:

• The name of the treatment or procedure for which you are going to be hospitalized
• The physician name, address, and phone number
• The hospital name, address, and phone number

HIRSP Inpatient Hospitalization Prior Approval Staff are Available:

• Monday through Friday, 7:30 a.m. to 4:30 p.m., Central Standard Time
• After hours, please leave a message on our confidential voice mail and we will return your call the next business day

How You Will be Notified About HIRSP's Determination

As soon as possible, we will inform you and your doctor by letter whether the hospitalization meets established guidelines of medical necessity for your situation and the terms of the HIRSP policy. If there are any questions, a HIRSP nurse or doctor will review the plan of care with your provider.

If you have a question about any of these procedures, you can contact the HIRSP Care Management team at: 1-866-841-6572.

When to Request a Prior Approval of Health Care Services

This only applies to those participants enrolled in HIRSP 1,000, HIRSP 2,500, HIRSP 5,000, or HIRSP Health Savings Account.

The Plan Administrator’s prior approval is required in order to receive benefits for charges for covered expenses for certain health care services covered under this policy. Health care services requiring the Plan Administrator’s prior approval are listed below. You are responsible for assuring that the required prior approval is received before health care services are provided by calling 1-866-841-6572 or faxing the request for prior approval to 1-608-226-4777. Failure to comply with the prior approval requirement will result in no coverage for such health care services.

To assure that health care services are covered, you must obtain the Plan Administrator’s prior approval before you receive any of the following health care services:

1. Surgical services for morbid obesity;
2. Reduction mammoplasty, septoplasty, and blepharoplasty;
3. Transplant services;
4. Any durable medical equipment and prosthetics costing more than $1,500;
5. Pain management procedures as follows:
   1. percutaneous intervertebral disc procedures:
      (intradiscal electrothermal therapy (IDET), intradiscal electrothermal annuloplasty (IDEA), percutaneous intradiscal radiofrequency thermocoagulation (PIRFT), nucleoplasty, laser assisted disc decompression (LADD), percutaneous disc decompression, chemonucleolysis;
   2. radiofrequency neuroablation (neurolysis) of the facet joint nerves;
   3. facet joint injections and medial branch nerve blocks;
   4. trigger point injections;
   5. epidural injections, other than epidural injections provided to the pregnant participant in connection with labor or delivery of a newborn child or due to surgery;
   6. sacroiliac joint injections; and
   7. artificial intervertebral disc replacement (lumbar artificial disc replacement (LADR) and intervertebral disc prosthesis).
6. The following additional health care services, except when such services are provided in an emergency:
   1. Spinal surgeries;
   2. PET scans
   3. MRA studies
   4. Dental repair related to an injury.
7. Inpatient admissions. Approval must be received for non-emergency admissions, within three business days prior to the confinement. Please see Section X.;
8. Tay-Sachs testing.
9. Outpatient visits and transitional treatment arrangements for treatment of alcoholism, drug abuse and nervous or mental disorders beyond 50 visits per calendar year.

New medical or biomedical technology or new surgical methods or techniques may be experimental. You are strongly encouraged to seek prior approval for these health care services to ensure they are payable under this policy.

If you don’t obtain the Plan Administrator’s prior approval before you receive any health care service listed above, benefits for that health care service will not be payable under this policy.

After the Plan Administrator receives a prior approval request, the Plan Administrator will make a determination on whether or not to approve benefits for the health care service based upon the information available to the Plan Administrator at the time the Plan Administrator receives the prior approval request.  The Plan Administrator will send you its written response to the request, telling you whether the health care service is covered.

However, even if a health care service is approved in writing by the Plan Administrator, no benefits will be paid unless, after receiving the proof of claim, the Plan Administrator determines that benefits are payable for that approved health care service under the terms, conditions, exclusions, limitations, and all other provisions of this policy, and your coverage is in effect at the time the health care service is provided to you and the health care services are provided by a Medicaid-certified health care provider.  Even if a health care service is approved by the Plan Administrator under this subsection and provided by a Medicaid-certified provider, benefits are still subject to all terms, conditions and provisions of this policy.

The proof of claim may differ from the prior approval request. This means that the Plan Administrator’s approval of benefits is not its final decision and does not guarantee payment of benefits later. This means that benefits may not be paid if, after reviewing the proof of claim, the Plan Administrator determines that the health care service is not covered under this policy.

Mail or Fax Prior Approval Requests to:

HIRSP Care Management
Attention Prior Approval
P.O. Box 8961
Madison, WI 53708-8961
Fax: 608-226-4777

How You Will be Notified About HIRSP's Determination

After review of this information, we will send a letter with our determination to you and your doctor. We can also fax this information to your doctor if requested.

If you have a question about any of these procedures, you can contact the HIRSP Care Management team at: 1-866-841-6572.