Out of Network Authorization

Workers' compensation health care networks contract with doctors and hospitals to treat injured employees. If your employer participates in a workers’ compensation network, you must use doctors, hospitals, and other health care providers in the network to get care for a work-related injury. The only exception is for emergencies or if the network approves a referral to an out-of-network provider. (Reference)

If you would like to request an out of network provider, please complete the following information for review.

Please attach all medical documentation including Statement of Medical Necessity, medical notes and any additional information needed to provide our Texas HCN of the necessity of the services requested.

Contact Prime Health Services, Inc. for further assistance at 1 (866) 348-3887.

NOTE: This is not an approval of services and any preauthorization services will have to be met prior to services being rendered.
Patient Information
Treating Provider Information
Referred Out of Network Provider Information
Out of Network Referral Reasoning
Requested Referred Services
About PHS

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PHS Contact Info
Toll Free: (866) 348-3887

(615) 329-4751

Prime Health Services, Inc.
PO Box 660675
Dallas, TX 75266-0675
Service Lloyd's Contact Info
P.O. Box 26850
Austin, TX 78755

Voice: (512) 212-7064
Claim Dept. Fax: (512) 231-8248