Administration Services - Financial Authorization (Form 17) Request

Financial Authorization (Form 17) Request on the Maccabi app and Maccabi Online :

What is a financial authorization (Form 17)?

Form 17 is a financial commitment document indicating that Maccabi HMO will fund medical services not available within Maccabi facilities.
The authorization is provided to the member before receiving the service or treatment and is required for Maccabi to cover the service (except for emergency room and ambulance authorizations, typically issued after the fact).
Nonetheless, Maccabi operates many clinics and employs specialists across a wide range of medical fields. If an alternative service is available within Maccabi's network, the member might be referred there instead of receiving an authorization.

Where are the medical services provided?

Which medical services require an authorizations to be submitted?

• Emergency room visits
• Ambulance Transport
• Doctor's exams or treatment at outpatient clinics in public hospitals or Assuta
• Planned (elective) hospitalizationfor scheduled exams or treatment
• Surgeries in public hospitals (excluding Assuta and private surgeries)
• Surgeries performed by private surgeons (non-Maccabi) in private hospitals - for Maccabi Zahav and Maccabi Sheli members only
• Imaging tests - CT, MRI, and advanced scans

What documents are required to file a request?

The request must include scanned documents:

• For emergency room visits - attach a discharge summary letter
• For medical evacuation/ambulance transport - attach a payment request and an evacuation report
• For a doctor's exam, treatment, surgery, or hospitalization - attach a doctor's referral or a recent hospital visit summary, along with a hospital order (containing a treatment code)

Where can I submit a financial authorization request?

Maccabi Online - online request
Maccabi app - if you have a referral from Maccabi
Maccabi app - if you have a referral from a source outside of Maccabi
At a medical center - via email, fax or directly at a medical center

To submit an online request, supporting documents must be scanned.

What will authorized services cost?

• If a deductible is required, you will be prompted to confirm the payment when printing the financial authorization form. The payment will comply with Maccabi's approved collection procedures>>
• Cost varies depending on the service type for which financial authorization is requested - contact Maccabi via Maccabi
• Online, the Maccabi app, email, fax, the Maccabi Call Center at *3555, or by reaching out to a medical center directly.
• If you don't have a standing order, you can print the authorization via Maccabi Online after updating your credit card information on file.

What is the expected response time?

• In most cases, inquiries will be processed within 5 working days.
• Authorization requests for ambulance services or emergency room visits will be processed within 10 working days

I requested an authorization but did not use it

If you didn't use the authorization received from Maccabi, the collected deductible will be automatically refunded to you.

Should the authorization be printed?

Print the authorization before arriving at the service provider.
You can print the authorization via Maccabi Online or at personal service stations in medical centers and select hospitals.

If you don't have a standing order, you can print the authorization via Maccabi Online after updating your credit card information on file
*The authorization does not need to be printed for care received at Assuta.