CurrentCentenePolicy XC-PAF-6083

Outpatient California Medi‑Cal Authorization Form

Form and instructions to request prior authorization for outpatient services for California Medi‑Cal members served by Community Health Plan of Imperial Valley/Health Net Community Solutions, including standard and urgent request pathways. Affects requesting and servicing providers submitting authorization requests and supporting clinical documentation.

Policy Summary

PayerCentene

PolicyOutpatient California Medi‑Cal Authorization Form

Policy CodePolicy XC-PAF-6083

Change TypeAdministrative — no material clinical/coverage changes

Effective Date03 01 2026

Next Review Date

Key ActionSubmit completed Outpatient Prior Authorization Form (and supplemental form if more than four procedure codes) via fax to 800-743-1655 or transplant fax 833-769-1141; urgent requests must be signed by the physician.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7 daysstandard determination timeframe

72 hrsurgent determination timeframe

4codes on main form before supplemental

2fax numbers provided

Imperial Countylocal health authority

Coverage and Administrative Notices

Administrative coverage notice

Administrative coverage stance and requirements

ALL of the following

An authorization is not a guarantee of payment; member must be eligible at the time services are rendered.
Services must be a covered benefit and medically necessary with prior authorization per Plan policy and procedures.
Submit completed Outpatient Authorization Form (and Outpatient Authorization Supplemental Form if more than four procedure codes) via the fax numbers provided; standard and transplant fax numbers are listed on the form.
All required fields must be completed; incomplete forms will be rejected and copies of supporting clinical information are required; lack of clinical information may result in delayed determination.

Policy Summary

PayerCentene

PolicyOutpatient California Medi‑Cal Authorization Form

Policy CodePolicy XC-PAF-6083

Change TypeAdministrative — no material clinical/coverage changes

Effective Date03 01 2026

Next Review Date

SourceLink

On This Page

Procedure, Diagnosis, and Form Coding

Procedure and diagnosis codesmixed

CPT/HCPCS	Primary and additional procedure codes requested on form
ICD-10	Diagnosis code required

Procedure code count before supplemental form — indicator for >4 procedure codes

ThresholdMore than 4 procedure codes on the main Outpatient Prior Authorization Form triggers use of the Outpatient Authorization Supplemental Form.

When to attachAttach the Outpatient Authorization Supplemental Form when the authorization request exceeds four (4) procedure codes.

SubmissionSubmit the supplemental form together with the Outpatient Prior Authorization Form to the applicable fax number listed on the main form.

Form statusThe supplemental page is optional and only required if more than four procedure codes are being requested.

Submission, Documentation, and Request Instructions

Prior Authorization

Submission and Urgency Instructions

Complete and fax the completed Outpatient California Medi-Cal Authorization Form to the appropriate fax number below. For transplant-related requests, use the Transplant Fax. Urgent requests must be clearly indicated and signed by the requesting physician to receive priority handling.

Standard requests: Determination within 7 calendar days of receiving all necessary information.
Urgent requests: If certified as urgent (non–life-threatening but requires action within 72 hours to avoid complications or severe pain), mark as Urgent and ensure physician signature.
Fax numbers: General authorization fax 800-743-1655; Transplant fax 833-769-1141.

Documentation Required

Required Request Fields

The authorization request must include all required request fields. Incomplete requests will be rejected or delayed. Provide procedure and diagnosis coding, dates, and quantity information as indicated on the form.

Primary Procedure Code: CPT or HCPCS (required). Include applicable Modifier(s).
Additional Procedure Codes: CPT or HCPCS and Modifiers (if applicable).
Diagnosis Code: ICD-10 (required).
Start Date or Admission Date and End Date or Discharge Date: Use MMDDYYYY format (required).
Total Units/Visits/Days: Specify quantity requested for each procedure line.
For multiple procedures, repeat procedure code, modifiers, dates, and units on additional lines as provided on the form.

Denial Risk

Form Completeness and Supporting Documentation

All required fields on the form must be completed and copies of supporting clinical documentation must be included. Missing information or lack of clinical documentation may result in rejection or delayed determination.

Ensure member information (name, date of birth MMDDYYYY, Member ID) is complete.
Attach copies of all supporting clinical records relevant to the requested service (progress notes, test results, prior authorizations, operative reports, transplant evaluation materials when applicable).
An authorization is not a guarantee of payment; member eligibility and benefit coverage will be verified at time of service.
Incomplete forms or missing clinical copies may be returned or denied — include everything requested on the form to avoid delays.

Key Definitions and Forms

Urgent request — definition and criteria

DefinitionAn urgent request is a request certified as urgent and medically necessary to treat an injury, illness, or condition within 72 hours to avoid complications, unnecessary suffering, or severe pain.

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

Turnaround timeDetermination for an urgent request is within 72 hours of receiving all necessary information.

Use caseIndicate 'Urgent request' on the Outpatient Prior Authorization Form when the clinical situation meets the urgency criteria described above.

Outpatient Authorization Supplemental Form — when to use supplemental form

NameOutpatient Authorization Supplemental Form.

PurposeOptional supplemental page to record additional procedure codes when an authorization request includes more than four (4) procedure codes.

Submission instructionsWhen applicable, submit this supplemental form together with the Outpatient Prior Authorization Form to the applicable fax number (see main form: 800-743-1655 or transplant fax 833-769-1141).

Required fieldsFields marked with an asterisk on the supplemental form are required; incomplete forms may be rejected per the main form instructions.