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Child Health Plan Plus (CHP+) HMO Authorization Form, July 2016


The service coordinator shall notify the appropriate HMO in its service area that a child has been determined eligible for Early Intervention Services and shall send to the HMO the completed "Child Health Plan Plus Individualized Family Service Plan Health Maintenance Organization Authorization Form," along with a copy of the child's IFSP.


The HMO will verify coverage of the child, then authorize payment for Early Intervention Services and return the authorization form to the service coordinator within five working days of receipt of the request. The HMO must provide written authorization using the "Child Health Plan Plus Individualized Family Service Plan Health Maintenance Organization Authorization Form" for all Early Intervention Services on the IFSP that will be paid for through CHP+. Other HMO authorization forms are not allowable.




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