CurrentCentene | California Health NetPolicy N/A

Medicare Inpatient Authorization — Prior Authorization Form and Requirements

This document governs the process and required information for requesting prior authorization for Medicare inpatient services for Centene/California Health Net members; it affects providers requesting standard or expedited inpatient admissions, including behavioral health and facility providers.

Policy Summary

PayerCentene | California Health Net

PolicyMedicare Inpatient Authorization — Prior Authorization Form and Requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the inpatient authorization form with all required fields and supporting clinical information to request standard or expedited determinations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

14 daysstandard determination timeframe from receipt of request

Expeditedexpedited requests require physician signature and prioritized handling

Requiredall required fields must be completed or form will be rejected

Copies requiredsupporting clinical information must be provided or determinations may be delayed

Submission and Decision Criteria

Submission and decision criteria

Operational criteria for submission and decision timelines:

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

Copies of all supporting clinical information must be provided; lack of clinical information may delay determination.

Form must include member information, requesting and servicing provider information, primary and additional procedure codes (CPT/HCPCS) with modifiers, diagnosis code (ICD-10), admission/discharge dates, and total units/visits/days requested.

Form must include inpatient service type number (service type codes such as Skilled Nursing Facility, Sub-Acute, Transplant, Vaginal Delivery, etc.).

Decision timeframe

Policy Summary

PayerCentene | California Health Net

PolicyMedicare Inpatient Authorization — Prior Authorization Form and Requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the inpatient authorization form with all required fields and supporting clinical information to request standard or expedited determinations.

SourceLink

On This Page

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Prior Authorization Process and Requirements

Prior Authorization

Standard prior authorization process

Complete and fax the inpatient authorization form for standard (elective) admissions. Determination will be made as expeditiously as the enrollee's health condition requires but no later than 14 calendar days after receipt of the request.

Prior Authorization

Expedited prior authorization

For requests where waiting under the standard timeframe could place the enrollee's life, health, or ability to regain maximum function in serious jeopardy, submit an expedited request signed by the physician to receive priority handling.

Documentation Required

Form completeness and documentation requirement

All required fields on the form must be completed; incomplete forms will be rejected. Copies of all supporting clinical information are required and lack of clinical information may result in delayed determination.

Complete every required field on the authorization form.
Attach copies of supporting clinical documentation to avoid delays.

Billing Rule

Authorization is not payment guarantee

An authorization is not a guarantee of payment; the member must be eligible at the time services are rendered and services must be covered and medically necessary for payment to apply.

Key Definitions

Expedited request

DefinitionAn expedited request is one where waiting for a decision under the standard timeframe could place the enrollee's life, health, or ability to regain maximum function in serious jeopardy.

Signature requirementExpedited requests must be signed by the physician to receive priority handling.

When to useUse for situations the enrollee or physician believes meet the jeopardy criteria rather than standard (elective) timing.

Inpatient service type

DefinitionInpatient service type is recorded as a numeric service type number entered in the form's service type boxes (e.g., 402, 492, 992).

Examples and codes402 = Skilled Nursing Facility; 492 = Sub-Acute; 992 = Transplant; 720 = Vaginal Delivery; 970 = Medical; 427 = Rehab; 121 = Long Term Acute Care; 414 = Premature/False Labor.

Location on form'INPATIENT SERVICE TYPE' section with instruction 'Enter the Service type number in the boxes.'

OpenPayer

Medicare Inpatient Authorization — Prior Authorization Form and Requirements

Submission and Decision Criteria

Form Coding and Quantity Fields

Prior Authorization Process and Requirements

Key Definitions

CPT/HCPCS	Primary and additional procedure codes (CPT/HCPCS) and modifiers requested on the form
ICD-10	Diagnosis code field (ICD-10) for admission