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: Aug 1, 2022
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: Feb 26, 2024
Modified: Feb 26, 2024
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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: Feb 26, 2024
Modified: Feb 26, 2024
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Inpatient TRICARE Service Request/Notification Form

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

Use this form for the following types of admissions: physical health, mental health, acute rehab facility/unit, long term acute care, skilled nursing facility (SNF), substance use disorder, partial hospitalization program (PHP) and intensive outpatient program (IOP).

Created: Aug 1, 2022
Modified: Aug 18, 2020
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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: Aug 1, 2022
Modified: Apr 30, 2019
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