Memorial Hermann Prior Authorization Form: Submission, Timeline, and Appeals

The Memorial Hermann prior authorization form is a request your provider submits to confirm that a planned service is medically necessary and covered before treatment begins. You can download it as a PDF from the plan’s provider resources page, fill it out on screen, and fax it to the line that matches your plan type, or your provider can submit it electronically through the HealthTrioConnect portal.1Memorial Hermann. Memorial Hermann Prior Authorization Form2Memorial Hermann Health Plan. For Providers

Where To Get the Form

The Medicare Advantage (Part C) version of the form is hosted in the plan’s provider file library and can be completed on screen before printing or faxing.1Memorial Hermann. Memorial Hermann Prior Authorization Form Providers with portal credentials can skip the PDF and start a request directly at mhapexprovider.healthtrioconnect.com, which allows digital file attachments and real-time submission.2Memorial Hermann Health Plan. For Providers

If you’re a member trying to figure out whether a specific service even needs authorization before you call your doctor, Memorial Hermann customer service at (855) 645-8448 can confirm the requirement.3Memorial Hermann Health Plan. Prior Authorization Requirements

What To Fill In

The form itself is short. Incomplete submissions are the most common reason requests get kicked back, so gather everything before you start.

Patient and Member Information

Enter the patient’s full legal name, date of birth, and member ID exactly as they appear on the health plan ID card. A middle initial where a full middle name is on file, or a single transposed digit in the member ID, can delay processing.3Memorial Hermann Health Plan. Prior Authorization Requirements

Provider Details

The ordering physician’s name, practice address, National Provider Identifier (NPI), and Tax Identification Number (TIN) are all required.3Memorial Hermann Health Plan. Prior Authorization Requirements The NPI is a unique 10-digit identifier assigned to every healthcare provider. If the ordering physician and the rendering provider are different people, include both NPIs on the form.1Memorial Hermann. Memorial Hermann Prior Authorization Form

Diagnosis and Procedure Codes

List the ICD-10 diagnosis codes that explain why the patient needs the service and the CPT or HCPCS codes that identify the specific procedure or item being requested.1Memorial Hermann. Memorial Hermann Prior Authorization Form The two codes work as a pair: the diagnosis establishes the medical reason, and the procedure code states exactly what is being proposed.

Clinical Documentation

Attach supporting records: recent lab results, imaging reports, office visit notes, or a letter of medical necessity from the treating physician. The plan’s medical review team uses this documentation to verify the service meets clinical criteria. Thin or outdated records are the second biggest reason authorizations stall, right behind missing form fields. Send the most recent and relevant records rather than the whole chart.

Expedited Review

If the referring provider believes the standard review timeline could seriously jeopardize the patient’s life, health, or ability to regain maximum function, the form includes a section to request expedited review.1Memorial Hermann. Memorial Hermann Prior Authorization Form Check the expedited box and include a brief clinical justification. Standard requests that should have been marked urgent lose valuable time.

Where To Send It

Memorial Hermann accepts prior authorization requests through fax or the provider portal. The fax lines run 24 hours a day, seven days a week.

  • Commercial plans fax: (832) 476-1962
  • Medicare Advantage plans fax: (832) 476-2194
  • Behavioral health (all plans) fax: (281) 823-7355
  • Acute inpatient ER admits and post-acute care fax: (832) 476-2193
3Memorial Hermann Health Plan. Prior Authorization Requirements

Match the fax number to the plan type printed on the member’s ID card. Sending a Medicare Advantage request to the commercial fax line is a common routing error that costs days. Keep the fax transmission confirmation as proof of the date and time the plan received the request.

Providers with HealthTrioConnect access can submit the request electronically by logging in, completing the authorization fields on screen, and uploading clinical documents.2Memorial Hermann Health Plan. For Providers The portal confirms receipt immediately and lets you track pending requests without calling. To check on a submitted request by phone, call (855) 645-8448.3Memorial Hermann Health Plan. Prior Authorization Requirements

How Long the Decision Takes

Turnaround depends on plan type and urgency. For 2026, Memorial Hermann publishes these timelines:

  • Fully insured commercial plans: 3 calendar days for standard requests.
  • Self-funded and hybrid plans: 3 business days for standard requests, with an outside limit of up to 15 calendar days.
  • Medicare Advantage standard requests: 7 calendar days.
  • Medicare Advantage Part B drugs, standard: 72 hours.
  • Urgent commercial requests: 72 business hours.
  • Expedited Medicare Advantage requests: 72 hours.
  • Expedited Medicare Advantage Part B drugs: 24 hours.
  • Post-stabilization: 1 hour.
  • Post-service review for all plans: 30 calendar days.
3Memorial Hermann Health Plan. Prior Authorization Requirements

The plan notifies both the provider and the member of the decision through the secure portal or by mail. An approval includes an authorization number and the window during which the service must be performed. A denial or partial approval explains the clinical rationale and your appeal rights.

Which Services Need Authorization

Memorial Hermann publishes a prior authorization grid each year listing every service category that needs pre-approval. Submitting without authorization on any of them usually means a denied claim. The 2026 grid flags:

  • All planned inpatient admissions. Emergency admissions at Memorial Hermann facilities need notification only; admissions at other contracted facilities need both notification and concurrent authorization.
  • Advanced imaging: CT, MRI, MRA, nuclear studies, PET, SPECT, and image-guided radiation therapy.
  • Outpatient surgery in ambulatory surgical centers or outpatient hospital settings, with musculoskeletal and pain management services (orthopedic surgery, steroid injections, nerve blocks, neurostimulators) specifically listed.
  • Any medical pharmacy drug exceeding $1,000 in billed charges per claim line.
  • Any durable medical equipment, orthotic, or prosthetic device over $500.
4Memorial Hermann Health Plan. 2026 Prior Authorization Grid

If the Request Is Denied

A denial isn’t the end of the road. Memorial Hermann provides two tracks depending on whether the issue is clinical or administrative.

Internal Appeal

For clinical denials, where medical management determined the service isn’t medically necessary, download and complete the Appeal of Clinical Non-Certification by Medical Management form from the plan’s appeal rights page.5Memorial Hermann Health Plan. Appeal Rights and Process You can also use the general Appeal Reference Form or write a detailed cover letter. Include any new clinical documentation that supports medical necessity.

Mail appeal materials to:

Memorial Hermann Health Plan
Attention: Appeals
PO Box 19909
Houston, TX 77224-19095Memorial Hermann Health Plan. Appeal Rights and Process

For employer-sponsored group health plans governed by federal ERISA rules, you have at least 180 days from the date you receive the denial notice to file.6eCFR. 29 CFR 2560.503-1 – Claims Procedure That window starts when the notice arrives, not when you get around to reading it.

External Review

If the internal appeal is denied, you can request independent external review through a Texas Department of Insurance-assigned Independent Review Organization. In most cases, you must exhaust the internal appeal first. The exception: if you have a life-threatening condition, you can request IRO review after the first denial. For non-life-threatening preauthorization disputes, the IRO has 20 days to issue a decision; for life-threatening cases, 3 days.7Texas Department of Insurance. Independent Review Organization FAQ

Prescription Drug Requests Go a Different Route

The prior authorization form on the provider resources page is for medical services. Prescription drug prior authorizations, formulary exceptions, and step therapy exceptions are handled by Capital Rx, which administers Memorial Hermann’s pharmacy benefits. Prescribers can call Capital Rx at (833) 502-3346 or fax requests and clinical records to (833) 434-0563.8Memorial Hermann Health Plan. Utilization Management, Appeals, and Grievances Drug-specific clinical criteria are posted at mhhpcomdocs.consolmx.com so prescribers can see what’s required before submitting.