Out Of Network Referral Request

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OUT OF NETWORK Referral Request*
Y
*
OU MUST SUBMIT CLINICAL DOCUMENTATION TO SUPPORT YOUR REQUEST
NPN Lines of Business
NPN Phone Numbers
! PacifiCare Secure Horizons
Referrals
(253) 573-1880X2
Fax (253) 627-4708
! Molina Healthy Options
Main Line
(253) 627-4638
Fax (253) 573-9511
Member Services
(253) 573-1880
Fax (253) 573-9511
Case Managers
(253) 627-4638
Fax (253) 627-4708
PLEASE NOTE: This Referral does not ensure payment of services. All claims are subject to normal policy limitations, current eligibility, and plan
Requirements. AUTHORIZATION NUMBERS WILL BE FAXED TO PCP & SPECIALIST THE DAY AFTER PROCESSING.
PATIENT INFORMATION
Patient Name_________________________________________ Date of Birth___________________ Member ID#:______________________
Phone Number____________________________
FROM: PRIMARY CARE PROVIDER
TO: SPECIALIST PROVIDER OR FACILITY
Name__________________________________________________
Name_________________________________________________
Phone______________________ Fax _______________________
Phone______________________ Fax_________________________
Date Referral Made_______________________________________
Address________________________________________________
(Following authorization by NPN, valid for 3 months)
Authorization by NPN required for out of network providers
PATIENT REFERRED FOR
! Out of Network: Consult Only. This visit must be authorized
! Diagnostic Studies
by NPN prior to seeing the patient. Any further treatment must be
Use Franciscan Facilities
requested by the PCP and submitted to NPN for prior approval
! Laboratories Services
! Comments ___________________________________________
Use Quest for all lab services
________________________________________________________
________________________________________________________
Diagnosis and ICD-9 Codes_______________________________________________________________________________________________
Primary Care Providers Signature__________________________________________________________________________________________
→THESE SERVICES REQUIRE PRIOR AUTHORIZATION (Fax to 253-627-4708)←
Inpatient Hospital
! OutPatient Hospital
Name of Facility_______________________________________________________
!
Surgery/CPT Code_______________________________ Date of Service_______________________________________________________
DME_______________________________________________________________________
!
! Chemo/Radiation
! Chiropractic
! Home Health
! MRI
Alternative Care
Therapies
C:staging472BC1D9-12B5-0847EBin472BC1D9-12B5-0847EB.docC:staging472BC1D9-12B5-0847EBin472BC1D9-12B5-
! IV
! Skilled Nursing Facility
! PET Scan
! Acupuncture
! Occupational
0847EB.docC:staging472BC1D9-12B5-0847EBin472BC1D9-12B5-0847EB.doc
! OTHER _________________
! Massage Therapy
! Physical Therapy
! Naturopathy
! Speech Therapy
Signature of the Requesting Provider_______________________________________________
Mail Claims:
Northwest Physicians Network
AUTHORIZATION #______________________________________
P.O. Box 2117
______________________________________________________
Tacoma, WA 98401-2117
Initials__________________________ Date__________________
PAYMENT SUBJECT TO CURRENT ELIGIBILITY AT THE TIME OF SERVICE
K:MedmgmtFORMSReferralsOut of Network
Revised 11/2/2007

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