Health Net Oregon Commercial Plan
Request for Prior Authorization
Instructions: Use this form to request prior authorization for POS, PPO and EPO. Type or print; complete all sections. Attach sufficient clinical
information to support medical necessity for services or your request may be delayed. Health Net Health Plan of Oregon, Inc. (Health Net) will provide notification of decision by phone,
mail, fax or other means. Washington requests for immediate review (any request for approval of an intervention, care or
treatment where passage of time without treatment would,
in the judgment of the provider, result in an imminent emergency room visit or hospital admission and
deterioration of the member's health status) should be
requested by telephone at 1-888-802-7001.
Fax the completed form to the Prior Authorization Department at 1-800-495-1148.
MEMBER INFORMATION
Member Name:
Subscriber #:
Check appropriate box.
Product:
Other insurance / policy #
Designate type of request. Check appropriate box.
Explain clinical necessity for urgent/expedited request
Designate service requested. Check appropriate box.
Anticipated date of service:
/habilitative
services (PT, OT, ST)
/habilitative
services (HH/PT/OT/ST)
Remaining authorized visits?
Does plan have volume limits?
Has member used or will use their last visit within next 24 hours?
PROVIDER INFORMATION
Requesting / Ordering Provider Information
Servicing Provider - Where will member receive services
First and Last Name of requesting provider
Tax ID / NPI
Name of hospital or Provider of services / product (no abbreviations)
Address
Tax ID # of above
National Provider Identifier of above
City State Zipcode
Address
Area code
Telephone # + ext.
Fax #
City State Zipcode
Requesting / Ordering Contact Name
Telephone # + ext
Area code
Telephone # of above + ext.
Name of Primary Care Physician (PCP) (if applicable)
Assistant surgeon required?
Name
Tax ID/NPI
Area code
Telephone # + ext.
Fax #
Anesthesiologist required?
CLINICAL INFORMATION
ICD-10 code(s) (REQUIRED)
Diagnosis Description
Date of Onset/injury
ICD-10 code(s) (REQUIRED)
# of visits
Describe service requested (Note: Billed CPT codes not approved require clinical review upon submission of claim and report)
Why is the service necessary? (Attach diagnostics, X-ray reports, progress notes, results of conservative treatment)
Is the member terminally ill? (Life expectancy less than 6 months)
Is the member aware?
Signature of Requesting Physician
Date
Note: Provider agrees that the results of the care or treatment rendered under approved authorization shall be forwarded to the requesting physician or primary care physician named above for inclusion in the patient’s medical record. Health Net uses evidence-based information and national guidelines to make authorization decisions. Contracted provider agrees to accept Health Net’s payment as payment in full and will not bill the member for any amount for services rendered hereunder except for member copayments, deductibles, and coinsurances required under the member’s plan. This form is not a guarantee of payment. Charges for services rendered to patients whose coverage is no longer in effect are the patient's responsibility. Patient eligibility and covered benefits must be verified at www.healthnet.com before rendering any medical services.