Referral Prior Authorization Form - Kern Legacy Health Plan
ADVERTISEMENT
1Kern Legacy Health Plan - Utilization Management
st
1115
Truxtun Ave, 1
Floor, Bakersfield CA 93301
Phone: 661 868-3280 or 855 308-5547 │ Fax: 661 868-3291
REFERRAL & PRECERTIFICATION REQUEST FORM
ALL BOLD FIELDS ARE REQUIRED.
You will receive a determination within the number of days stated by the urgency marked:
○
○
○
Standard - 5 days
Urgent - 3 days
Emergency - 24 hours
Patient Information
Last Name:
First Name:
Suffix:
M/I:
11 Digit Member ID:
Date of Birth:
Sex:
PCP:
Address:
City
Does the patient have other health coverage?
State:
Zip:
Day Time Phone:
○
○
No
Yes _________________________
Subscriber Information
Last Name:
First Name:
Relationship to Patient:
Provider Information
Requesting Physician:
NPI:
Phone:
Fax:
Provider Signature:
Date
Referral Request Details
(required for all referral)
Precertification Details
(required for all precertifications)
EPO providers must refer to other providers in the EPO
Precertification is required for all inpatient, most outpatient
Level Network. Care will be directed in network. Referrals are not
services, CPAP supplies, and DME over $250 on the EPO and PPO
required for PPO Level consults.
benefit levels.
Type of Service:
Date of Service:
Requested Physician:
○
○
○
/
/
Inpatient
Outpatient
Observation
NPI:
Specialty:
Requested Provider/Facility Name:
Reason for Request
(include any symptoms and test information)
INCLUDE ALL SUPPORTING DOCUMENTATION WITH THIS FORM.
ICD-10 Diagnosis Code
(at least ONE diagnosis code is required for ALL requests)
CODE
DESCRIPTION
CODE
DESCRIPTION
1.
3.
2.
4.
CPT Treatment Codes and or HCPCS codes
(at least ONE code is required for ALL PRECERTIFICATIONS and SPECIALTY REFERRALS)
CODE
DESCRIPTION
QNTY
CODE
DESCRIPTION
QNTY
1.
6.
2.
7.
3.
8.
4.
9.
5.
10.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical