Outpatient California Health Net Medi-Cal Authorization Form
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Form and instructions governing prior authorization requests for outpatient services for Health Net Medi-Cal members in California; used by requesting and servicing providers to submit authorization requests, supplemental procedure codes, and supporting clinical information.
No material clinical or coverage changes in this revision.
Authorization Coverage and Form Processing
Authorization form coverage and processing
Covered when ALL of the following are met:
ALL of the following
- Standard determinations: within 5 business days after receiving all necessary information.
- Urgent determinations: processed within 72 hours when the request is certified/signed by the requesting physician.
Procedure, Diagnosis Codes and Supplemental Form Rules
| CPT/HCPCS | Primary and additional procedure codes requested on the form |
| ICD-10 | Diagnosis code field |
| Modifier | Modifier fields associated with procedure codes |
Submission Requirements, Timelines, and Documentation
Submit completed form + supporting clinical info; observe decision timeframes
Complete all required fields on the outpatient prior authorization form and submit copies of supporting clinical information. Standard determinations are made within 5 business days of receiving all necessary information; urgent requests (physician‑signed) are processed within 72 hours. Fax forms to the numbers listed on the form (general outpatient fax or transplant fax as applicable).
- All required fields must be filled in; incomplete forms will be rejected.
- Submit copies of all supporting clinical information with the request.
- Standard determination timeframe: within 5 business days after receipt of all necessary information.
- Urgent determination timeframe: 72 hours for physician‑certified urgent requests.
- Fax submissions: general outpatient fax 1-800-743-1655; transplant fax 1-833-769-1141.
Incomplete forms, missing documentation, and payment disclaimer
Incomplete forms will be rejected and lack of supporting clinical information may delay determination. An authorization is not a guarantee of payment—member eligibility, benefit coverage, and medical necessity must be met at the time services are rendered.
- Incomplete forms are rejected.
- Failure to include supporting clinical documentation may delay the determination.
- Authorization does not ensure payment; member eligibility and plan benefits/medical necessity still apply.
Physician signature required for urgent requests
To receive priority (urgent) processing, the urgent request must be signed by the requesting physician.
- Urgent requests require the requesting physician’s signature to qualify for 72‑hour processing.
Key Definitions and Disclaimers
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