Imperial Health holdings

AUTH FORM: IMPERIAL AUTH FORM ( please click for AUTH form)

RETRO Authorizations

MUST MAILED RETRO AUTH TO:

Imperial Health Holdings

Attention: Retro Claim Authorization <<<<<<<( must include this header when mailing out )

PO Box 60075

Pasadena CA 91116

We can only submit a request by MAIL. We can not submit a retro authorization by fax.

Please attached.

-AUTH FORM ( AUTH FORM LISTED ABOVE)

-DENIAL (EOB/ LETTER ETC.. )

-REFERAL PCP

-MEDICAL REPORT FROM THAT DOS

Once approved mail the claim to imperial with denial attached.

Claims Tel: 1-626-838-5100 ext. 3

Claims Mailing Address: PO Box 60075, Pasadena CA 91116

Claims Payer ID (Office Ally Electronic Submission): IHHMG

UTILIZATION MANAGEMENT

UM Outpatient Tel: 1-626-838-5100 ext. 1

UM Outpatient Fax: 1-626-283-5021

UM Inpatient Tel: 1-626-598-3099

UM Inpatient Fax: 1-626-380-9134

UM Ambulatory Tel: 1-626-365-0202

UM Ambulatory Fax: 1-626-380-9964

MEMBER SERVICES

Member Services Tel: 1-626-838-5100 ext. 2

Member Services Fax: 1-626-380-9129

CONTRACTING

Contracting Tel: 1-626-838-5100 ext. 4

Contracting Fax: 1-626-380-9142

PROVIDER SERVICES

Provider Services Tel: 1-626-838-5100 ext. 5

Provider Services Fax: 1-626-380-9142

ELIGIBILITY

Eligibility Tel: 1-626-838-5100 ext. 6

CREDENTIALING

Credentialing Fax: 1-626-380-9963

COMPLIANCE

Compliance Hotline Fax: 1-888-708-5377

Last update: 01/23/2024 DP