Pacific Health Care Out-of-Network Referral Form

Frequently Asked Questions about Out-of-Network

Referral Requests

Why submit a Referral?

• Obtain authorization for a referral to an Out-of-Network provider (NON PHC).
• Claim re-processed for payment recovery without an approved referral form.

When to submit a Referral?

• Submit Referral form within 90 days prior to service date.
• Requested Information and/or documentation must be submitted to PQH within 7 business days.

Who submits a Referral?

• Preferably the PCP, however, any PMAG physician may submit a referral.

What form to use?

• Use ONLY the most updated Out-of-Network Referral Request Form (Revised 10/2019A).

When to go outside of the network?

• In-net service or product is not available by a PHC provider.
• There is a medical need to obtain outside of the network.

How to submit?

• Fill out legibly and complete all required elements. FAX to PQH at (808)943-8732. Incomplete forms will not be processed.
• Urgent and Stat requests require pertinent clinical reason.

PQH Criteria for “NOT APPROVED” Requests:

• In-net provider is available to provide service or product.

PQH Hours:

• Monday through Friday from 9 a.m. to 5 p.m.
• Closed on most major holidays.
• Fax machine accessible 24 hours at (808)943-8732