ONLINE REFERRAL
Referral Forms
Interactive Forms
PEER Review (Interactive Form Under Maintenance)
Hines uses MCG as UR criteria. However, if the review proceeds to a physician, other applicable standards as well as mitigating circumstances are also considered. If you have any questions, please call 800-944-9401.
Hines is an independent utilization review organization retained by your insurer or health plan. For information regarding pre-certification requirements or policies, please refer to your benefits card for their website or instruction on how to find the pre-certification requirements and procedures of your insurer or claim payer.
We may call you or send a letter if additional information appears to be needed to complete the review. If information is not received in the time specified, we will review based upon the information provided.
Downloadable PDF Forms
Forms are available by clicking the links. These may be printed, faxed or mailed to the address which appears on the top of each form. They require that you have Acrobat Reader. If it is not already installed on your machine, click to download it for free.
Prescreen Request
Prescreen Request
Downloadable Excel Forms
A Claim Submission form is available by clicking on the following link. It should be completed and then emailed, with all supporting documents, to the email address which appears at the top of the form.
Hines & Associates, Inc. is a nationwide, independent leader in personalized managed health care, focusing on what's important to you—comprehensive services with the program excellence and cost containment that you demand.
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