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Authorizations

Concurrent Hospice Services and Curative Care Log

Hospice providers must submit a consolidated (palliative and curative) treatment plan, to include this monthly activity log, to Health Net Federal Services, LLC (HNFS) Case Management each month a beneficiary under age 21 is receiving concurrent curative care services.

Please fax this information to: 1-888-965-8438

  • Created: Sep 30, 2019
  • Modified: Sep 30, 2019
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EHHC Agency Attestation

When requesting Extended Care Health Option (ECHO) Home Health Care (EHHC) services, the agency should complete the EHHC Agency Attestation Form. 

Attach this completed form to your online request.

  • Created: Aug 16, 2018
  • Modified: Apr 15, 2018
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EHHC Provider Attestation

When requesting Extended Care Health Option (ECHO) Home Health Care (EHHC) services, the provider should complete the EHHC Provider Attestation Form. 

Attach this completed form to your online request.

  • Created: Aug 16, 2018
  • Modified: Apr 15, 2018
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Inpatient TRICARE Service Request/Notification Form

Network providers requesting an elective admission prior authorization or submitting an inpatient notification admission are required to submit requests online. Non-network providers are encouraged to submit online as electronic requests save time and improve accuracy. 

  • Created: Sep 9, 2019
  • Modified: Apr 15, 2018
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Letters of Attestation

A letter of attestation can be submitted by the provider, in lieu of additional clinical documentation, when requesting authorization for certain services. Learn more on our Letters of Attestation page. Attach this completed form to your online request.

  • Created: Apr 30, 2019
  • Modified: Apr 30, 2019
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