Yes! You can use AI to fill out Health Net Applied Behavioral Analysis (ABA) Recommendation and Referral Form (24-989)
The Health Net Applied Behavioral Analysis (ABA) Recommendation and Referral Form (24-989) is an official document required by the California Department of Health Care Services (DHCS) to establish medical necessity for ABA therapy services for Medi-Cal members. It must be completed by a licensed physician or psychologist and includes member information, diagnosis, referral reasons, and provider signature, ensuring the member is connected to an appropriate in-network ABA provider through Health Net's Behavioral Health Autism Center. This form is critical for initiating ABA services for individuals, particularly those with autism spectrum disorder, and ensures compliance with DHCS requirements. Today, this form can be filled out quickly and accurately using AI-powered services like Instafill.ai, which can also convert non-fillable PDF versions into interactive fillable forms.
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Form specifications
| Form name: | Health Net Applied Behavioral Analysis (ABA) Recommendation and Referral Form (24-989) |
| Number of pages: | 1 |
| Language: | English |
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How to Fill Out Health Net ABA Referral Form 24-989 Online for Free in 2026
Are you looking to fill out a HEALTH NET ABA REFERRAL FORM 24-989 form online quickly and accurately? Instafill.ai offers the #1 AI-powered PDF filling software of 2026, allowing you to complete your HEALTH NET ABA REFERRAL FORM 24-989 form in just 37 seconds or less.
Follow these steps to fill out your HEALTH NET ABA REFERRAL FORM 24-989 form online using Instafill.ai:
- 1 Navigate to Instafill.ai and upload the Health Net ABA Recommendation and Referral Form (24-989) or select it from the available form library.
- 2 Enter the member's information, including full name, date of birth, and Medi-Cal ID number in the designated fields.
- 3 Provide the parent or caregiver's details, including their full name, relationship to the member, and contact phone number.
- 4 Fill in the clinical information, including the member's primary diagnosis, the referring physician or licensed psychologist's name and contact phone number, and the reason(s) for the ABA referral.
- 5 Indicate whether ABA is recommended (Yes or No) and provide any additional treatment recommendations as applicable.
- 6 Specify whether the parent or caregiver has already chosen an in-network ABA provider, and if not, note that the Behavioral Health Autism Center will assist in connecting them to one.
- 7 Have the referring physician or licensed psychologist provide their signature, license type and ID number, and the date, then submit the completed form to the Health Net Behavioral Health Autism Center via email at [email protected] or fax at 855-427-4798.
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Frequently Asked Questions About Form Health Net ABA Referral Form 24-989
This form fulfills the requirement set by the Department of Health Care Services (DHCS) that Applied Behavioral Analysis (ABA) services require a medical necessity recommendation from a physician or licensed psychologist. It serves as the official referral document to connect members with ABA services through Health Net.
This form must be completed by a licensed physician or licensed psychologist only. Parents, caregivers, or other individuals cannot complete this form on behalf of the referring provider.
You will need the member's full name, date of birth, and Medi-Cal ID number. Make sure this information is accurate to avoid delays in processing the referral.
The form requires the parent or caregiver's full name, their relationship to the member (e.g., parent, legal guardian), and a contact phone number. This information helps the Behavioral Health Autism Center reach the appropriate person if needed.
The completed form can be given directly to the parent/caregiver or their chosen in-network ABA provider. Alternatively, the referring physician or licensed psychologist can submit it directly to the Health Net Behavioral Health Autism Center via email at [email protected] or by fax at 855-427-4798.
If no in-network ABA provider has been chosen, the referring physician or licensed psychologist should submit the completed form directly to the Behavioral Health Autism Center. A utilization review clinician will then contact the parent/caregiver to connect them with an in-network provider. The parent/caregiver can also call 888-935-5966 to obtain a list of in-network ABA providers.
The referring provider must provide their signature, their license type and ID number, and the date of signing. This information is required to validate the medical necessity recommendation.
Yes, the form includes both a 'Yes' and 'No' checkbox for ABA recommendation. If ABA is not recommended, the referring physician or licensed psychologist should check 'No' and may provide additional treatment recommendations in the designated field.
Yes, there is a dedicated field for additional treatment recommendations. The referring physician or licensed psychologist can use this space to note any other treatments they recommend alongside or instead of ABA services.
Yes, AI-powered services like Instafill.ai can help auto-fill form fields accurately, saving time for busy medical offices and caregivers. These tools can pre-populate member information, provider details, and other fields, reducing manual data entry errors.
You can upload the ABA Recommendation and Referral Form PDF to Instafill.ai, where the AI will guide you through filling in each field accurately. Once completed, you can download, print, or submit the form electronically to Health Net's Behavioral Health Autism Center.
If you have a flat, non-fillable PDF version of this form, Instafill.ai can convert it into an interactive fillable form. This allows you to type directly into the fields digitally rather than printing and filling it out by hand.
The primary diagnosis field should contain the member's main medical or behavioral diagnosis that is driving the referral for ABA services, such as Autism Spectrum Disorder (ASD). This information helps Health Net assess medical necessity for the requested services.
The form does not specify an exact processing time, but once submitted to the Health Net Behavioral Health Autism Center, a utilization review clinician will review the referral. If no in-network provider has been chosen, the clinician will contact the parent/caregiver to assist with provider selection.
Yes, this form is specifically designed for Health Net members, including those covered under Health Net of California, Inc., Health Net Community Solutions, Inc., and Health Net Life Insurance Company, which are subsidiaries of Health Net, LLC and Centene Corporation.
Compliance Health Net ABA Referral Form 24-989
Validation Checks by Instafill.ai
1
Member Name is Complete and Not Abbreviated
Validates that the Member Name field contains a full legal name, including both first and last name, and is not left blank or filled with initials or abbreviations. This is critical for accurately identifying the Medi-Cal member and matching the referral to the correct health plan record. If the name is incomplete or abbreviated, the form may be rejected or routed to the wrong member's file.
2
Member Date of Birth Format and Validity
Validates that the Member Date of Birth is entered in a recognizable date format (e.g., MM/DD/YYYY) and represents a logically valid date that is not in the future. Since ABA services are typically provided to children and young adults, the date of birth should also reflect an age range consistent with eligibility for ABA services under Medi-Cal. An invalid or missing date of birth will prevent proper member identification and eligibility verification.
3
Medi-Cal ID Format and Completeness
Validates that the Member Medi-Cal ID field is populated and conforms to the expected format for California Medi-Cal identification numbers, which are typically numeric and of a specific length. An incorrect or missing Medi-Cal ID will prevent Health Net from locating the member's coverage and processing the referral. If this field fails validation, the form cannot be submitted successfully to the Behavioral Health Autism Center.
4
Parent/Caregiver Name is Fully Provided
Validates that the Parent/Caregiver Name field contains a full name (first and last) and is not left blank. This field is essential for Health Net staff to contact the appropriate responsible party if the in-network ABA provider has not yet been chosen. An incomplete or missing name will delay outreach and could prevent the member from being connected to ABA services in a timely manner.
5
Parent/Caregiver Relationship to Member is Specified
Validates that the Relationship to Member field is filled in with a clear descriptor such as 'Parent,' 'Legal Guardian,' 'Caregiver,' or another recognized relationship type, and is not left blank. This information is necessary to confirm the authority of the individual to make healthcare decisions on behalf of the member. If this field is missing, it may raise compliance concerns regarding consent and authorization.
6
Parent/Caregiver Phone Number Format and Completeness
Validates that the Parent/Caregiver Phone Number is provided and follows a standard U.S. phone number format (e.g., (XXX) XXX-XXXX or XXX-XXX-XXXX) with exactly 10 digits, excluding formatting characters. This contact information is critical for the Autism Center utilization review clinician to reach the parent or caregiver, especially when no in-network ABA provider has been selected. A missing or malformed phone number will obstruct follow-up communication.
7
Primary Diagnosis Field is Not Blank
Validates that the Primary Diagnosis field is completed and contains a meaningful clinical description or ICD-10 diagnosis code relevant to the referral for ABA services. ABA services under DHCS require medical necessity documentation, and the primary diagnosis is a core component of that justification. A blank or vague entry in this field may result in the referral being denied or returned for additional information.
8
Referring Physician or Licensed Psychologist Name is Fully Provided
Validates that the Referring Physician or Licensed Psychologist Name field contains a complete name and is not left blank or filled with a title alone. The form explicitly states it must be completed by a physician or licensed psychologist, making this field essential for establishing the authority and accountability of the referral. An incomplete name may render the form non-compliant with DHCS requirements.
9
Referring Provider Contact Phone Number Format and Completeness
Validates that the Contact Phone Number for the referring physician or licensed psychologist is provided and adheres to a standard U.S. phone number format with 10 digits. Health Net may need to contact the referring provider for clarification or additional clinical information. A missing or incorrectly formatted phone number will impede communication and could delay processing of the referral.
10
Referral Reason is Provided and Not Blank
Validates that the Referral Reason field contains a substantive explanation for why the member is being referred for ABA services and is not left blank or filled with placeholder text. This field supports the medical necessity determination required by DHCS and provides clinical context for the Behavioral Health Autism Center. An empty or insufficient referral reason may result in the referral being flagged for review or returned to the provider.
11
ABA Recommended Checkbox is Exclusively Selected
Validates that exactly one of the two ABA Recommended checkboxes (Yes or No) is selected, and that both are not simultaneously checked or both left unchecked. This binary selection is a required clinical determination that drives the processing of the referral form. If neither or both options are selected, the form is ambiguous and cannot be acted upon by the Behavioral Health Autism Center.
12
In-Network ABA Provider Selection Checkbox is Exclusively Selected
Validates that exactly one of the two In-Network ABA Provider Chosen checkboxes (Yes or No) is selected, ensuring the form clearly indicates whether the parent or caregiver has already identified a provider. This determination dictates the next steps in the referral workflow, including whether Health Net staff must intervene to connect the family with a provider. Leaving both unchecked or selecting both creates an unresolvable ambiguity in the process.
13
Conditional Workflow Compliance When No In-Network Provider is Chosen
Validates that when the 'No' checkbox is selected for In-Network ABA Provider Chosen, the form is being submitted directly to the Health Net Behavioral Health Autism Center rather than only to the parent or caregiver. Per the form instructions, if no provider has been chosen, the referring physician or licensed psychologist is responsible for submitting the form to Health Net so a utilization review clinician can follow up. Failure to route the form correctly in this scenario will delay the member's access to ABA services.
14
Physician or Licensed Psychologist Signature is Present
Validates that the Signature field for the physician or licensed psychologist is not blank, confirming that an authorized provider has reviewed and attested to the contents of the form. DHCS requires that ABA service recommendations come from a physician or licensed psychologist, and the signature is the legal attestation of that requirement. A missing signature renders the form invalid and non-compliant with regulatory standards.
15
License Type and ID Number Format and Completeness
Validates that the License Type and ID Number field is populated with both a recognizable license type (e.g., MD, DO, PhD, PsyD) and a corresponding license identification number, and that the number is not blank or composed of placeholder characters. This information is necessary to verify that the signing individual is a qualified physician or licensed psychologist as required by DHCS. An incomplete or unrecognizable license entry may result in the referral being rejected for failing to meet medical necessity documentation standards.
16
Signature Date Format, Validity, and Recency
Validates that the Signature Date is entered in a recognizable date format (e.g., MM/DD/YYYY), represents a valid calendar date, is not set in the future, and is reasonably recent to ensure the referral reflects a current clinical assessment. Outdated referrals may not satisfy DHCS medical necessity requirements, and a future date would indicate a data entry error. If the date fails validation, the form should be returned to the provider for correction before submission.
Common Mistakes in Completing Health Net ABA Referral Form 24-989
Many people enter a nickname, preferred name, or partial name instead of the member's full legal name as it appears on their Medi-Cal records. This can cause a mismatch with Health Net's system, leading to processing delays or rejection of the referral. Always use the member's full legal name exactly as it appears on their Medi-Cal ID card or insurance documents. AI-powered form filling tools like Instafill.ai can help by cross-referencing and auto-populating the correct legal name to avoid discrepancies.
Filers often enter the date of birth in inconsistent formats such as MM/DD/YY, DD/MM/YYYY, or written out (e.g., 'January 5, 2015'), which can cause confusion or data entry errors during processing. Health Net requires a standardized format, and inconsistencies may delay authorization. Always use the MM/DD/YYYY format for the date of birth field. Tools like Instafill.ai automatically format dates correctly, eliminating this common source of error.
The Medi-Cal ID number is a critical identifier, and errors such as transposed digits, missing characters, or entering a different ID (e.g., a Social Security Number or insurance member ID) are very common. An incorrect Medi-Cal ID can result in the referral being rejected or attributed to the wrong member. Double-check the Medi-Cal ID directly from the member's Benefits Identification Card (BIC) before submitting. Instafill.ai can help validate the format of the Medi-Cal ID to catch obvious errors before submission.
Filers sometimes leave the 'Relationship to Member' field blank or enter overly vague terms like 'guardian' without specifying the legal relationship (e.g., 'legal guardian,' 'biological mother,' 'adoptive father'). This can create ambiguity during the authorization process and may require follow-up contact. Be specific and use the legally recognized relationship term. This field is required and must be completed accurately to ensure the correct party is contacted and authorized to make decisions.
Phone numbers are frequently entered without area codes, with extra spaces, or in non-standard formats (e.g., missing dashes or parentheses), making it difficult for Health Net staff to follow up if needed. Both the parent/caregiver phone number and the referring physician's contact phone number are critical for communication. Always include the full 10-digit phone number with area code in a consistent format such as (XXX) XXX-XXXX. Instafill.ai can automatically format phone numbers correctly to prevent this issue.
A common mistake is entering a vague diagnosis such as 'autism' instead of the full clinical diagnosis with the appropriate ICD-10 code (e.g., 'Autism Spectrum Disorder, F84.0'). An incomplete diagnosis description may not satisfy the medical necessity requirement set by DHCS, potentially causing the referral to be denied. The primary diagnosis should be specific, clinically accurate, and ideally include the relevant diagnostic code. Physicians and psychologists should ensure the diagnosis aligns with their clinical documentation.
Many referrers write only brief or generic statements like 'needs ABA therapy' in the referral reason field, which does not adequately justify medical necessity. A thorough referral reason should describe the member's specific behavioral challenges, functional impairments, and why ABA services are clinically indicated. Insufficient detail can lead to denial or requests for additional information, delaying the member's access to services. Provide a clinically substantive explanation that supports the recommendation.
Filers sometimes forget to check either the 'Yes' or 'No' box for ABA recommendation, or accidentally check both, leaving the form ambiguous and incomplete. Since this checkbox directly communicates the physician's or psychologist's clinical recommendation, leaving it unclear can result in the form being returned or rejected. Carefully review the form before submission to ensure exactly one box is checked. This is a required field and must reflect the clinician's definitive recommendation.
The 'In-network ABA Provider Chosen: Yes/No' question is frequently left blank, which creates confusion about next steps for Health Net's Behavioral Health Autism Center. If 'No' is not checked, the Autism Center will not know to reach out to connect the family with an in-network provider, potentially delaying care. Always check the appropriate box and, if 'No' is selected, advise the parent/caregiver to call 888-935-5966 to obtain a list of in-network providers. This step is critical for ensuring continuity of care.
Some forms are submitted without a signature, with an initials-only signature, or with a signature so illegible that it cannot be verified, which invalidates the form entirely. DHCS requires a formal recommendation from a licensed physician or psychologist, and the signature is the legal attestation of that recommendation. The form must be signed in full by the referring clinician before submission. If the form is a flat, non-fillable PDF, Instafill.ai can convert it into a fillable version that supports digital signatures, making this step easier and more reliable.
Clinicians often forget to include their license type (e.g., MD, DO, PhD, PsyD) alongside their license number, or they enter an incorrect or expired license number. Since only physicians and licensed psychologists are authorized to complete this form, the license information is essential for verifying the referrer's credentials. Always include both the license type abbreviation and the full, current license number as issued by the California Medical Board or Board of Psychology. Instafill.ai can help prompt clinicians to include all required credential details.
The signature date is frequently left blank or filled in incorrectly (e.g., using the appointment date rather than the date the form was actually signed). An undated form may be considered incomplete or invalid, and an incorrect date can raise compliance concerns. Always enter the exact date the form is signed in MM/DD/YYYY format. This date is important for establishing the timeline of the referral and ensuring the recommendation is current and valid for processing by Health Net.
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