Request for Prior Authorization Form

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Completion of the Inpatient California Medi-Cal Prior Authorization – Medi-Cal (PDF), Inpatient California Medi-Cal Prior Authorization – Community Health Plan of Imperial Valley or Inpatient California Medi-Cal Prior Authorization – CalViva Health (PDF) form or the Outpatient California Medi-Cal Authorization – Medi-Cal (PDF), Outpatient California Medi-Cal Prior Authorization – Community Health Plan of Imperial Valley or Outpatient California Medi-Cal Authorization – CalViva Health (PDF) are the primary method used by Health Net to manage the referral process for fee-for-service (FFS) providers directly contracting with Health Net. It helps monitor the care provided to members and provides instructions to the specialist regarding authorized services.

Guidelines for Referrals

Primary care physicians (PCPs) and specialists should follow the guidelines below when completing the Inpatient California Medi-Cal Prior Authorization – Medi-Cal (PDF), Inpatient California Medi-Cal Prior Authorization – Community Health Plan of Imperial Valley or Inpatient California Medi-Cal Prior Authorization – CalViva Health (PDF) form or the Outpatient California Medi-Cal Authorization – Medi-Cal (PDF), Outpatient California Medi-Cal Prior Authorization – Community Health Plan of Imperial Valley or Outpatient California Medi-Cal Authorization – CalViva Health (PDF) to request prior authorization of services. Providers are required to complete all fields on the form as follows to expedite the process of these requests.

  • If the number of units or visits is not indicated in the Professional field, only one visit is authorized by Health Net. That visit must take place within 60 days of the order date. If more than one consultation is required, another request must be submitted to Health Net for review.
  • Designate the type of request (urgent or elective).
  • Designate service requested to determine prior authorization requirements.
  • ICD-10 codes and CPT codes and descriptions are required fields.
  • Providers must attach all pertinent medical information in order for the request to be reviewed for medical necessity.