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

2023 UM Holiday Schedule (After hours Phone Open)
New Year’s Day – Monday, January 2, 2023
Memorial Day – Monday, May 29, 2023
Independence Day – Tuesday, July 4, 2023
Labor Day – Monday, September 4, 2023
Thanksgiving Day – Thursday, November 23, 2023
Friday after Thanksgiving – Friday, Nov. 24, 2023
Christmas – Monday, December 25, 2023

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