*REQUIRED FIELDS Pre-Authorization Request Form

1 URGENCY OF Request : Standard 5 days Urgent 3 days Emergency 24 hours KERN LEGACY HEALTH PLANS Employee and Retiree Health Plan Options Pre-Authorization Request form 1115 Truxtun Ave, 1st Floor | Bakersfield CA 93301 | Ph: 661 868-3280 |UM Fax: 661 868-3291 | Kern Legacy Share Select | Kern Legacy Network Plus authorization form Revised December 7, 2018 Fax Request to *REQUIRED FIELDS Patient Information Last Name*: First Name*: Suffix: MI: Sex*: M F Member ID*: DOB*: PCP*: Other Health Coverage*: No Yes Street Address: City/State/Zip: Phone*: Subscriber Information (if the patient is a minor) Last Name: First Name: Relationship to Patient: Provider Information Requesting Physician*: NPI*: Phone*: Provider Signature*: Date*: Fax*: Mark the Kern Legacy Health Plan that your patient is enrolled in*: Type of Pre-Authorization Request : Kern Legacy Share Select Kern Legacy Network Plus Outpatient Inpatient There is NO Out-of-Network Benefit.

2 Care will be directed in-network by the Plan. CPT, HCPC, Rev Code(s)*: 1. QNTY 5. QNTY 2. QNTY 6. QNTY 3. QNTY 7. QNTY 4. QNTY 8. QNTY Service Date(s): COMMENTS: Processing of your Request will not begin until all required FIELDS are complete and supporting documentation is received. The urgency of the Request is based on medical necessity. Not obtaining prior authorization does not constitute urgency. Requests will be directed to preferred network providers. Network Plus members can elect to use Plus Network providers at their discretion due to higher out-of-pocket expenses associated with the benefit.

3 There is No Out-of-Network Benefit. Completion of this form is not a guarantee of approval or payment. Questions: Call (661) 868-3280 or (855) 308-5547. Requested Provider (if applicable): Place of Service*: DME (*CPAP/Breast Pump) Ashli Byrum Kern Medical Supply* Mercy Plaza Respiratory* Home Health Around the Clock Home Infusion ICS Hoffman Homecare Infusion Chemo Kern Medical - Additional Provider for Network Plus only: AIS Infusion Other Kern Medical Prosthetics & Orthotics Achilles Bakersfield Prosthetics Valley Institute of Prosth Radiology Kern Medical Kern Radiology Stockdale Radiology Truxtun Radiology Sleep Lab Sandman Speech Therapy Affiliated Speech Therapy PT OT Pair & Marotta Terrio In Office Hospital Facility Kern Medical Delano Regional Kern Valley Ridgecrest Regional Tehachapi Valley Valley Children s I/P Psych Bakersfield Behavioral Good Samaritan Kern Medical I/P Substance Abuse

4 Bakersfield Behavioral Good Samaritan Intensive O/P Program Bakersfield Behavioral Pine Meadows Aspire I/P Rehabilitation Health South Rehab Skilled Nursing Health South Rehab Surgery Center _____ Other Not Listed _____ Diagnosis Code(s)*: 1. 2. 3. 4. INSTRUCTIONS FOR form COMPLETION All FIELDS on the form with an asterisk (*) must be filled in for the Request form to be considered complete and clinical documentation to establish the medical necessity for requested services must be attached. Missing information or documentation can cause a delay in processing and/or denial of the Request .

5 EFFECTIVE JANUARY 1, 2019 NO REFERRAL/ authorization REQUIRED FOR A CONSULTATION WITH A CONTRACTED NETWORK SPECIALIST. Please Note: Follow-up visits and most procedures will still require prior authorization . Kern Legacy Network Plus: Two-Tiered health plan model. First tier uses a preferred provider network known as the EPO Network with no deductible. EPO Network specialties are limited to mostly Kern Medical providers and a number of local community providers. Additional tier uses a network of local community contracted providers, known as the Plus Network, which allows access to care outside of the traditional EPO Network.

6 This benefit must be elected by the member due to the deductible and higher out-of -pocket expense associated with service provided on this tier. Kern Legacy Share Select: EPO model, High-Deductible health plan using the Select Network. Specialties are limited to mostly Kern Medical providers and a limited number of local community providers. THERE IS NO OUT-OF-NETWORK BENEFIT. Urgency of Request : Mark the urgency of the Request . Urgent and Emergency requests should only be marked for services that require expedited review due to the patient s medical condition.

7 If an urgency is not marked, your Request will be processed as Routine . Patient Information: Complete this section with demographic information of the patient that you are treating. Member ID: Can be found on the patient s member ID card. Other Health Coverage: If the member has other health coverage, contact Health Plan Services to verify which plan is primary. If Kern Legacy is secondary to another health plan, no authorization is required. However, services must be provided by the appropriate network contracted provider for the services to be considered for coverage under a Kern Legacy Health Plan.

8 Subscriber Information: Complete only if the patient is a minor dependent. Provider Information: As the requesting provider, please complete all FIELDS . Be sure to include your signature and date. Type of Pre-Authorization Request : Mark whether your Request is for outpatient or inpatient service. Requested Provider: You MUST only enter contracted providers and/or facilities. There is NO Out-of -Network Benefit. Out-of -Network requests will be redirected to in-network providers or denied as Non-Participating Provider and returned back to the requesting provider.

9 The Plan will direct care to preferred network providers only. Direction or redirection of care in network by the plan does not constitute a modification of your Request for authorization . Place of Service: Only preferred network facilities have been included on this form . Mark the appropriate place of service. Diagnosis Code(s): At least one ICD-10 code must be entered. CPT/HCPCS/Rev Code(s): At least one code must be entered based on the type of service requested. Enter in the quantity being requested in applicable measurement ( units, number of visits, days, etc.)

10 Comments: Complete with any other pertinent information.