Mississippi Health Partners


General Information

Network Access Fee		$

Bill Access Fee To:		TPA Employer

No. Covered Employees:

Effective Date:

Plan Year:

		Benefit Plan Received

		UR Program Received

		Copy of ID Card Received

Group Information

Group Name:

Group Number:

Address:

City, State, Zip:

Phone:

Employer Contact/Title:

Contact's Address: (if different)

Contact's Phone: (if different)

Primary Contact Co.

Address:

City, State, Zip:

Phone:

Fax:

Contact:

TPA (Claims Processor)

Address:

City, State, Zip:

Claims Contact:

Phone:

Fax:

Claims Status Phone:

Eligibility Phone:

Benefits Phone:

Submission Address: (if different)

City, State, Zip:

Utilization Review Information

UR Vendor:

Phone:

		Pre-Certified Hospital Review Stay (Inpatient Admission Review)

		Outpatient Surgical Review

		Outpatient Diagnostic Review

		5 Days / 48 Hours OK

		Penalty to Failure to Pre-Certify

Prepared By

Email Address: