Lucent Health Precertification Form

Submit PPO Prior Authorization Request

Click here to view the PPO Prior Authorization List.

To request an EPO Prior Authorization, providers must complete prior authorization in John Muir's Epic Portal, by fax, or by phone.

This form is for John Muir Health PPO prior authorization only.

To initiate a PPO precertification for a patient,
please fill out the form below and attach medical documentation.
You can check the status of a previously submitted Prior Authorization by clicking here.

Member Information

Service Type

Referral/Service Type Requested

Provider Information

Servicing Provider Facility

Non-Par

Attach Supporting Clinical Documentation

Choose Files

Include any other clinical notes and supporting information below.

Clinical notes may include - Dates of Service, requested service, ICD-10 Code, CPT Code, HCPCs/J-Codes/T-Codes/L-Codes, Requested Units/Visits

Obtaining authorization does not guarantee payment. The plan retains the right to review benefit limitations and exclusions, beneficiary eligibility on the date of the service, correct coding, billing practices and whether the service was provided in the most appropriate and cost-effective setting of care.

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Submit PPO Prior Authorization Request

Click here to view the PPO Prior Authorization List.

To request an EPO Prior Authorization, providers must complete prior authorization in John Muir's Epic Portal, by fax, or by phone.

This form is for John Muir Health PPO prior authorization only.

To initiate a PPO precertification for a patient,
please fill out the form below and attach medical documentation.
You can check the status of a previously submitted Prior Authorization by clicking here.

Thank You!
Prior Authorization Request Received

Your precertification request has been received and logged into the system. The provided Requesting Provider Email should recive a confirmation reply shortly with a code that can be used to check the status of your authorization request.

Simple go to this page and enter the Provider NPI along with your code for this request (Auth Code: ) to check on the status.

Member Information

Service Type

Referral/Service Type Requested

Provider Information

Servicing Provider Facility

Submit PPO Prior Authorization Request

Click here to view the PPO Prior Authorization List.To request an EPO Prior Authorization, providers must complete prior authorization in John Muir's Epic Portal, by fax, or by phone.This form is for John Muir Health PPO prior authorization only.

To initiate a PPO precertification for a patient,please fill out the form below and attach medical documentation.You can check the status of a previously submitted Prior Authorization by clicking here.

Thank You!Prior Authorization Request Received

Your precertification request has been received and logged into the system. The provided Requesting Provider Email should recive a confirmation reply shortly with a code that can be used to check the status of your authorization request.

Simple go to this page and enter the Provider NPI along with your code for this request (Auth Code: ) to check on the status.

Member Information

Service Type

Referral/Service Type Requested

Provider Information

Servicing Provider Facility

Click here to view the PPO Prior Authorization List.

To request an EPO Prior Authorization, providers must complete prior authorization in John Muir's Epic Portal, by fax, or by phone.

This form is for John Muir Health PPO prior authorization only.

To initiate a PPO precertification for a patient,
please fill out the form below and attach medical documentation.
You can check the status of a previously submitted Prior Authorization by clicking here.

Thank You!
Prior Authorization Request Received