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Request for Prior Authorization Form

Provider Type

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

Guidelines for Referrals

  • 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.
Last Updated: 07/04/2024