Request for Prior Authorization Form
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Refer to the Prior Authorization (PA) Requirements List and Forms to determine which service require prior authorization and for information on where to submit PA requests based on the type of service, drug, device or procedure.
- The following forms are the primary method used by Health Net to manage the referral and authorization process for fee-for-service (FFS) providers directly contracting with Health Net.
- Providers are required to complete all fields on the form as follows to expedite the process of these requests.
- Inpatient (IP):
- Outpatient (OP)
- 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.