CurrentCentenePolicy N/A

Inpatient California Medi‑Cal Prior Authorization

Customize your policy alerts

Sign up for all Centene policy alerts

Know when Centene releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Governs prior authorization requests for inpatient services for California Medi‑Cal enrollees handled by Centene/Health Net. Applies to requesting and servicing providers submitting inpatient authorization requests and specifies required fields, timelines, and documentation expectations.

Policy Summary

PayerCentene

PolicyInpatient California Medi‑Cal Prior Authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionSubmit inpatient prior authorization with all required fields completed and include copies of supporting clinical information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7 daysstandard request determination timeframe

72 hoursurgent request determination timeframe

All required fieldsincomplete forms will be rejected

Copies requiredsupporting clinical information

Signaturephysician signature for priority

Form-based coverage and documentation requirements

Operational coverage notes and requirements stated on the form:

Authorization is not a guarantee of payment; member must be eligible at time services are rendered and services must be a covered benefit and medically necessary with prior authorization as per Plan policy and procedures.

All required form fields must be completed; incomplete forms will be rejected.

Copies of all supporting clinical information are required; lack of clinical information may result in delayed determination.

Select the applicable inpatient service type using the provided service type numbers (e.g., Delivery, Inpatient Rehab, Transplant, Skilled Nursing Facility, Surgical, Subacute, Miscellaneous).

Required procedure, diagnosis, and service coding

Required procedure and diagnosis coding on authorizationmixed

CPT/HCPCS	Primary and additional procedure codes requested on form
Modifier	Modifiers for procedure codes
ICD-10	Primary and additional diagnosis codes requested on form

Inpatient service type codingmixed

779	C-Section Delivery
720	Vaginal Delivery
427	Rehab
992	Transplant
970	Medical (Miscellaneous)
414	Premature/False Labor
402	Skilled Nursing Facility
411	Surgical
492	Subacute
6082	Form identifier (printed on form)

Prior authorization submission, timelines, and form requirements

Prior Authorization

Inpatient prior authorization submission and timelines

Submit the inpatient prior authorization using the form with all required fields completed and include copies of all supporting clinical information. Urgent requests must be certified as urgent and medically necessary and signed by the physician to receive priority; expect determinations within 72 hours for urgent requests and within 7 calendar days for standard requests.

Include primary procedure (CPT/HCPCS), modifiers, diagnosis (ICD-10), admission/start date, and other required fields shown on the form.
Attach copies of all supporting clinical documentation; lack of clinical information may delay determination.

Denial Risk

Form completion requirement

All required form fields must be completed; incomplete forms will be rejected.

The form marks required fields with an asterisk (*)—these must be filled in.
Failure to complete required fields will cause the submission to be rejected.

Request types and decision timeframes

inv-06: Urgent request definition

DefinitionUrgent requests must be certified as urgent and medically necessary to treat an injury, illness or condition within 72 hours to avoid complications, unnecessary suffering, or severe pain.

Physician signatureUrgent requests must be signed by the physician to receive priority handling.

Scope of urgencyApplies to requests that are not life‑threatening but require determination within 72 hours to prevent harm or severe pain.

inv-07: Standard request definition

DefinitionStandard requests: decision made as expeditiously as the enrollee's health condition requires but no later than 7 calendar days after receipt of the request.

TimingDetermination timeframe: up to 7 calendar days from receipt of request.

ApplicabilityUsed for non‑urgent prior authorization requests where the enrollee's condition does not meet urgent criteria.

Policy Summary

PayerCentene

PolicyInpatient California Medi‑Cal Prior Authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionSubmit inpatient prior authorization with all required fields completed and include copies of supporting clinical information.

SourceLink

On This Page

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentCentenePolicy N/A

Inpatient California Medi‑Cal Prior Authorization

Customize your policy alerts

Sign up for all Centene policy alerts

Know when Centene releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerCentene

PolicyInpatient California Medi‑Cal Prior Authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionSubmit inpatient prior authorization with all required fields completed and include copies of supporting clinical information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7 daysstandard request determination timeframe

72 hoursurgent request determination timeframe

All required fieldsincomplete forms will be rejected

Copies requiredsupporting clinical information

Signaturephysician signature for priority

Form-based coverage and documentation requirements

Operational coverage notes and requirements stated on the form:

All required form fields must be completed; incomplete forms will be rejected.

Copies of all supporting clinical information are required; lack of clinical information may result in delayed determination.

Select the applicable inpatient service type using the provided service type numbers (e.g., Delivery, Inpatient Rehab, Transplant, Skilled Nursing Facility, Surgical, Subacute, Miscellaneous).

Required procedure, diagnosis, and service coding

Required procedure and diagnosis coding on authorizationmixed

CPT/HCPCS	Primary and additional procedure codes requested on form
Modifier	Modifiers for procedure codes
ICD-10	Primary and additional diagnosis codes requested on form

Inpatient service type codingmixed

779	C-Section Delivery
720	Vaginal Delivery
427	Rehab
992	Transplant
970	Medical (Miscellaneous)
414	Premature/False Labor
402	Skilled Nursing Facility
411	Surgical
492	Subacute
6082	Form identifier (printed on form)

Prior authorization submission, timelines, and form requirements

Prior Authorization

Inpatient prior authorization submission and timelines

Include primary procedure (CPT/HCPCS), modifiers, diagnosis (ICD-10), admission/start date, and other required fields shown on the form.
Attach copies of all supporting clinical documentation; lack of clinical information may delay determination.

Denial Risk

Form completion requirement

All required form fields must be completed; incomplete forms will be rejected.

The form marks required fields with an asterisk (*)—these must be filled in.
Failure to complete required fields will cause the submission to be rejected.

Request types and decision timeframes

inv-06: Urgent request definition

DefinitionUrgent requests must be certified as urgent and medically necessary to treat an injury, illness or condition within 72 hours to avoid complications, unnecessary suffering, or severe pain.

Physician signatureUrgent requests must be signed by the physician to receive priority handling.

Scope of urgencyApplies to requests that are not life‑threatening but require determination within 72 hours to prevent harm or severe pain.

inv-07: Standard request definition

DefinitionStandard requests: decision made as expeditiously as the enrollee's health condition requires but no later than 7 calendar days after receipt of the request.

TimingDetermination timeframe: up to 7 calendar days from receipt of request.

ApplicabilityUsed for non‑urgent prior authorization requests where the enrollee's condition does not meet urgent criteria.

Policy Summary

PayerCentene

PolicyInpatient California Medi‑Cal Prior Authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionSubmit inpatient prior authorization with all required fields completed and include copies of supporting clinical information.

SourceLink

On This Page