Commercial plans – Outpatient Form

OUTPATIENT CALIFORNIA HEALTH NET COMMERCIAL AUTHORIZATION FORM Complete and Fax to: 844-694-9165 Transplant Fax to: 833-769-1142 Behavioral Health Requests Fax: 855-663-2244 Request for additional units.
Existing Authorization Units Standard requests - Determination within 5 business days of receiving all necessary information. Urgent requests - I certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within 72 hours to avoid complications and unnecessary suffering or severe pain. HMO POS PPO

• INDICATES REQUIRED FIELD X URGENT REQUESTS MUST BE SIGNED BY THE
  REQUESTING PHYSICIAN TO RECEIVE PRIORITY. MEMBER INFORMATION Last Name, First Date of Birth (MMDDYYYY) Member ID REQUESTING PROVIDER INFORMATION Requesting Provider Contact Name Requesting NPI Requesting TIN Phone Fax Requesting Provider Address City, State, ZIP SERVICING PROVIDER / FACILITY INFORMATION Same as Requesting Provider Servicing Provider Contact Name - Servicing NPI Servicing TIN - Phone Servicing Provider/Facility Name Address Fax City, State, ZIP AUTHORIZATION REQUEST Primary Procedure Code (CPT/HCPCS) (Modifier Additional Procedure Code (CPT/HCPCS) (Modifier Start Date OR Admission Date (MMDDYYYY) Diagnosis Code (ICD-10) Additional Procedure Code (CPT/HCPCS) (Modifier Additional Procedure Code (CPT/HCPCS) (Modifier End Date OR Discharge Date (MMDDYYYY) Total Units/Visits/Days (Enter the Service type number in the boxes) OUTPATIENT SERVICE TYPE 412 Auditory 422 Biopharmacy 712 Cochlear Implants & Surgery 299 Drug Testing 922 Experimental and Investigational Services 205 Genetic Testing & Counseling 249 Home Health 390 Hospice Services 290 Hyberbaric Oxygen Therapy 395 Infertility Diagnosis or Treatment 211 OB Ultrasound 410 Observation 997 Office Visit/Consult 210 Orthotics 794 Outpatient Services 171 Outpatient Surgery 202 Pain Management 147 Prosthetics 428 Second Opinion 201 Sleep Study 993 Transplant Evaluation 209 Transplant Surgery 724 Transportation Behavioral Health 533 BH Applied Behavioral Analysis 512 BH Community Based Services 515 BH Electroconvulsive Therapy 516 BH Intensive Outpatient Therapy 510 BH Medical Management 518 BH Mental Health /Chemical Dependency Observation 519 BH Outpatient Therapy 530 BH PHP 520 BH Professional Fees 522 BH Psychiatric Evaluation 521 BH Psychological Testing DME 417 Rental 120 Purchase (Purchase Price) 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. 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. Rev.05062025 XD-PAF-1654 1654*

Outpatient Authorization Supplemental Form This page is optional and meant to be used when an authorization request exceeds more than four (4) Procedure Codes. When applicable, please submit this form with the Outpatient Prior Authorization Form to the applicable fax number.

• INDICATES REQUIRED FIELD MEMBER INFORMATION *Date of Birth (MMDDYYYY)
• Medicaid/Member ID Last Name, First AUTHORIZATION REQUEST
  Additional Procedure Code Start Date OR Admission Date *End Date Total Units/Visits/Days Additional Procedure Code Start Date OR Admission Date End Date Total Units/Visits/Days Additional Procedure Code Start Date OR Admission Date End Date Total Units/Visits/Days Additional Procedure Code Start Date OR Admission Date End Date Total Units/Visits/Days Additional Procedure Code Start Date OR Admission Date End Date Total Units/Visits/Days Additional Procedure Code Start Date OR Admission Date End Date Total Units/Visits/Days Additional Procedure Code Start Date OR Admission Date End Date Total Units/Visits/Days Additional Procedure Code Start Date OR Admission Date End Date Total Units/Visits/Days Additional Procedure Code Start Date OR Admission Date End Date Total Units/Visits/Days Additional Procedure Code Start Date OR Admission Date
  End Date Total Units/Visits/Days Disclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Benefit and medically necessary with prior authorization as per Plan policy and procedures.
  Confidentiality: The information contained in this transmission is confidential and may be 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.