HPI Online Precertification Form

This form is for precertification of HPI's New England business only, with the following exceptions:

Southcoast Health employees and dependents receiving care in New England: call Conifer at 877-531-1139
Southcoast Health employees and dependents receiving care outside of New England: call United Health Care at 866-569-4345

For employees and dependents of employers located outside of New England, contact HPI's AchieveHealth program at 1-800-432-8421 or check the back of the patient's ID card for the appropriate contact number.

Not sure if your service requires precertification? Check here.

1. Submitter Information

Last Name*:

First Name*:

Fax*:

Phone*:

Email:

2. Group Information

Group ID:

Group Name*:

3. Patient Information

Member ID*:

Last Name*:

First Name*:

Date of Birth (MM/DD/YYYY)*:

Gender:

Address*:

City*:

State*:

ZIP Code*:

Phone Number*:

Email:

Relationship to Subscriber*:

3a. Newborn Patient Information (if applicable)

Newborn information not applicable

Last Name:

First Name:

Date of Birth (MM/DD/YYYY):

Gender:

Same Address as in Section 3

Address:

City:

State:

ZIP Code:

Phone Number:

Was the mother discharged?
Yes
No

Members

Log in to My Plan

Health and Wellness

Wellness

Discounts & Savings

Employers

Employer Portal

Forms and Resources

Health Programs

Health Care Reform and Compliance

Providers

Access Forms

Referral Portal

Log in to the Referral Portal

Brokers

Plans and Products

Health Care Reform and Compliance

Our Story

Careers

Providers

1. Submitter Information

2. Group Information

3. Patient Information

3a. Newborn Patient Information (if applicable)

4. Patient/Member Search