Medicare Inpatient Authorization — Health Net California
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This document governs prior authorization request completion and submission for Medicare inpatient admissions for Health Net California (Centene) members; it affects requesting and servicing providers and facilities submitting standard or expedited authorization requests.
No material clinical or coverage changes in this revision.
Inpatient Authorization Coverage Criteria
Inpatient authorization submission criteria
Submission and decision criteria for inpatient authorization requests
Timing and priority
- Standard (Elective) request: Determination will be made as expeditiously as the enrollee's condition requires but no later than 7 calendar days after receipt of the request.
- Expedited requests are for situations where waiting could seriously jeopardize the enrollee's life, health, or ability to regain maximum function; expedited requests must be signed by the physician to receive priority.
Procedure, Diagnosis, and Service Type Codes
| CPT/HCPCS | Primary and additional procedure codes requested on the form |
| ICD-10 | Diagnosis code required |
| 402 | Skilled Nursing Facility (service type code) |
| 492 | Sub-Acute (service type code) |
| 411 | Surgical (service type code) |
| 992 | Transplant (service type code) |
| 720 | Vaginal Delivery (service type code) |
| 779 | C-Section Delivery (service type code) |
| 970 | Medical (service type code) |
| 414 | Premature/False Labor (service type code) |
| 427 | Rehab (service type code) |
| 121 | Long Term Acute Care (service type code) |
Provider Submission Steps and Timelines
Submit form, standard determination timeframe, and expedited request rules
Complete the Medicare inpatient authorization form and fax it to the appropriate number. For standard (elective) admission requests, determinations are made as expeditiously as the enrollee's health condition requires but no later than 7 calendar days after receipt of the request. Expedited requests are for situations where waiting could seriously jeopardize the enrollee's life, health, or ability to regain maximum function and must be signed by the physician to receive priority.
- Standard (elective) fax number: 844-501-5713
- Behavioral health fax number: 855-663-2244
- Expedited requests require physician signature to receive priority
Attach supporting clinical documentation and use correct fax
Include copies of all supporting clinical information when submitting the form; all required fields must be completed. Incomplete forms may be rejected and lack of clinical information may delay determination. Use the general fax number for routine submissions and the behavioral health fax for BH-specific requests.
- All required fields must be filled in; incomplete forms will be rejected
- Copies of all supporting clinical information are required; lack may delay determination
- Fax general submissions to 844-501-5713; BH-specific requests to 855-663-2244
Request Type Definitions
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