Please complete the review below and submit via fax to 1-844-818-9289-2025

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The document is a Concurrent Review form for Health Net Federal Services, LLC, specifically for Residential Treatment Centers (RTC). It outlines the necessary information to be completed regarding a patient's clinical presentation, family participation, current medications, treatment plan revisions, discharge planning, and justification for additional treatment days. The document emphasizes the importance of privacy and compliance with relevant health regulations.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the fax number for TriWest Auth?

Fax to (866) 266-9820 or mail to address on the instruction page. Whom are you authorizing TriWest to disclose your PHI to? (This most likely will be a family member or friend.)

What is the fax number for TRICARE claims?

Dental Claims PlanLocationClaims Address TRICARE Dental Program OCONUS Service Area United Concordia TRICARE Dental Program P.O. Box 69452 Harrisburg, PA 17106 Fax: 1-844-827-9926 (toll-free) 1-717-635-4520 (toll)3 more rows Oct 3, 2023

How do I fax my TRICARE West referral?

Fax the application to Health Net Federal Services, LLC at 1-844-818-9289. You can also have your doctor send the form for you. Health Net Federal Services will look at the request once we receive both your family application and your provider application.