Complete and Fax to: 1-844-694-9165
OUTPATIENT CALIFORNIA HEALTHNET Transplant Fax to: 1-833-769-1142
COMMERCIAL AUTHORIZATION FORM HMO
Request for additional units. Existing Authorization Units POS
Standard requests - Determination within 5 business days of receiving all necessary information. PPO
I certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within
Urgent requests - 72 hours to avoid complications and unnecessary suffering or severe pain.
URGENT REQUESTS MUST BE SIGNED BY THE
*1654*
* INDICATES REQUIRED FIELD X REQUESTING PHYSICIAN TO RECEIVE PRIORITY.
Last Name, First *Date of Birth
MEMBER INFORMATION
*Member ID (MMDDYYYY)
REQUESTING PROVIDER INFORMATION Requesting Provider Contact Name
*Requesting NPI *Requesting TIN Phone
Requesting Provider Address *Fax
City, State, Zip
SERVICING PROVIDER / FACILITY INFORMATION
Same as Requesting Provider Servicing Provider Contact Name -
*Servicing TIN - Phone
*Servicing NPI
Servicing Provider/Facility Name Address Fax
City, State, Zip
AUTHORIZATION REQUEST
*Primary Procedure Code Additional Procedure Code *Start Date OR Admission Date *Diagnosis Code
(CPT/HCPCS) (CPT/HCPCS) (Modifier (MMDDYYYY) (ICD-10)
(Modifier
Additional Procedure Code Additional Procedure Code End Date OR Discharge Date Total Units/Visits/Days
(CPT/HCPCS) (Modifier (CPT/HCPCS) (Modifier (MMDDYYYY)
(Enter the Service type number in the boxes)
*OUTPATIENT SERVICE TYPE 410 Observation Behavioral Health
412 Auditory 997 Office Visit/Consult 533 BH Applied Behavioral Analysis DME
422 Biopharmacy 210 Orthotics 512 BH Community Based Services
712 Cochlear Implants & Surgery 794 Outpatient Services 515 BH Electroconvulsive Therapy 417 Rental
299 Drug Testing 171 Outpatient Surgery 516 BH Intensive Outpatient Therapy
922 Experimental and Investigational Services 120 Purchase
202 Pain Management 510 BH Medical Management
205 Genetic Testing & Counseling 518 BH Mental Health /Chemical Dependency Observation
147 Prosthetics
249 Home Health 519 BH Outpatient Therapy
428 Second Opinion (Purchase Price)
390 Hospice Services
201 Sleep Study 530 BH PHP
290 Hyberbaric Oxygen Therapy
993 Transplant Evaluation 520 BH Professional Fees
395 Infertility Diagnosis or Treatment
209 Transplant Surgery 522 BH Psychiatric Evaluation
211 OB Ultrasound
724 Transportation 521 BH Psychological Testing
ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED.
COPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION.
Disclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered benefit and medically necessary with prior authorization as per the Plan
policy and procedures. Health Net of California, Inc., Health Net Community Solutions, Inc. and Health Net Life Insurance Company are subsidiaries of Health Net, LLC and Centene Corporation. Health Net is a registered
service mark of Health Net, LLC. All other identified trademarks/service marks remain the property of their respective companies. All rights reserved.
Rev.02242021
Confidentiality:The information contained in this transmission is confidential and maybe protected under the Health Insurance Portability and Accountability Act of 1996. If you are not the intended recipient any use,
distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and destroy this document. XD-PAF-1654
