Authorizations

Provider Portal

Authorization Referral Form
Direct Referral Form
Case Management Referral Form

Preferred IPA UM Department
P.O. Box 4449
Chatsworth, CA 91313
Phone: (800) 874-2091
Fax: (800) 874-2093
Office Hours: Monday through Friday 8:30 A.M. – 5:00 P.M.

Authorization for Admission
Nurse Case Managers are available 24/7 to facilitate transfers to in network facilities and/or provide authorization for admission. Refer to attached contact list or call:
Monday – Friday 8:30 A.M. – 5:00 P.M (800) 874-2091
Monday – Friday 5:00 P.M. – 8:30 P.M. + Weekend & Holidays (800) 280-8008
Hospital Admit – ER Contact Notification

2021 UM Holiday Schedule (After hours Phone Open)
New Year’s Day – Monday, January 2, 2022
Memorial Day – Monday, May 30, 2022
Independence Day – Monday, July 4, 2022
Labor Day – Monday, September 5, 2022
Thanksgiving Day – Thursday, November 24, 2022
Friday after Thanksgiving – Friday, November 25, 2022
Christmas – Monday, December 26, 2022

Health Plan Prescription Drug Prior Authorization Form

Alignment Prescription Drug Prior Auth Link
Blue Cross Prescription Drug and Step Therapy Prior Auth Forms
Blue Shield Promise Health Plan Medi-Cal Prescription Drug and Step Therapy Prior Auth Forms
Blue Shield Promise Health Plan Medicare Prescription Drug and Step Therapy Prior Auth Forms
Brand New Day Prescription Drug Prior Auth Forms
Health Net Prescription Drug and Step Therapy Prior Auth Forms
Humana Prescription Drug Prior Auth Forms
LA Care CalMediconnect Prescription Drug Prior Auth Forms
LA Care Covered CA Prescription Drug and Step Therapy Prior Auth Forms
LA Care Medi-Cal CA Prescription Drug and Step Therapy Prior Auth Forms
Molina J-Code Drug Prior Authorization
WellCare Injectable Infusion Forms
WellCare Hep C Treatment Forms