Request For Prior Authorization For Health Net Of California

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Request for Prior Authorization

For Health Net of California

Instructions: Use this form to request prior authorization for Healthy Families, Healthy Kids & Medi-Cal.

Type or print; complete all sections. Attach sufficient clinical information to support medical necessity for services or your request may be delayed.

Fax the completed form to the Health Net Prior Authorization Department at (800) 743-1655. To check the status of your request, call (800) 421-8578,

(800) 628-2705 or (800) 642-4746.

MEMBER INFORMATION

Member Name:

Date of Birth

Last

First

(Mo/Day/Yr)

Subscriber #

Check appropriate box.

Product:

Healthy Families

Healthy Kids

Medi-Cal

Other Insurance/Policy #_______________

Work-related

Auto accident

CCS-Eligible Condition: Yes

Designate type of request. Check appropriate box(es)

Urgent for acute conditions requiring care within 72 hours or less

Elective for routine, non-urgent services

Notification only, for dialysis or prenatal maternity care

Confidential request: Member/Provider requests confidentiality. Health Net will not mail service-confirmation letter to member.

Designate service requested. Check appropriate box.

Anticipated date of service:_____________________

Office procedure

DME

Outpatient service/surgery

Diagnostic test

Inpatient admission

Home health services

Orthotics and prosthetics

Other

PROVIDER INFORMATION

To − Where will member receive services?

From

First and last name of requesting provider

Name of hospital or provider of services/product (no abbreviations)

MARC STONER

Address

Tax ID # of above

National Provider Identifier of above

190 S OAK AVE 1-4

City/State/ZIP

Address

OAKDALE, CA 95361

Area Code

Telephone # + OPTIONS and/or

Fax #

City/State/ZIP

EXT.

209

848-8410

848-0732

Contact person (REQUIRED)

Area Code

Telephone # of above + OPTIONS and/or EXT.

Name of primary care physician (PCP) (if applicable)

Assistant surgeon required?

Yes

Name

SAME

Area Code

Telephone # + OPTIONS and/or

Fax #

EXT.

Anesthesiologist required?

Yes

SAME

CLINICAL INFORMATION

ICD-9 code(s) (REQUIRED)

Diagnosis description

Date of onset/injury

CPT/HCPC code(s) (REQUIRED)

# of visits

Describe service requested (Note: Billed CPT codes not approved require clinical review upon

submission of claim and report)

Why is the service necessary? (Attach diagnostics, X-rays reports, progress notes, results of conservative treatment)

Signature of requesting physician

Date

Note: Provider agrees that the results of the care or treatment rendered under this authorization shall be forwarded to the requesting physician or primary care physician named above for inclusion in

the patient medical record. Provider agrees to accept Health Net’s payment as payment in full and will not bill the member for any amount for services rendered hereunder except for member

copayments, deductibles, and co-insurances required under the member’s plan. This form is not a guarantee of payment. Charges for services rendered to patients whose coverage is no longer in

effect are the patient's responsibility. Eligibility and benefits must be verified before rendering any medical services at

Health Net Determination

Services approved

Authorization number

Valid date range of authorization

Decision date