Outpatient Authorization Form for California Health Net Medi‑Cal (Transplant-related services)
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This document is an outpatient prior authorization request form used by providers to request authorization for outpatient services (including transplant evaluation and transplant surgery) for Health Net of California Medi‑Cal members. It governs what information must be submitted to obtain prior authorization and informs timing expectations for standard and urgent requests.
No material clinical or coverage changes in this revision.
Coverage Criteria
An authorization is not a guarantee of payment. Member eligibility must be verified at the time services are rendered, and services must be a covered Health Plan Benefit and medically necessary with prior authorization according to Plan policy and procedures. Providers must ensure all required form fields are completed and submit copies of all supporting clinical information; incomplete forms will be rejected and lack of clinical information may result in delayed determination.
Requested Codes on Form
| CPT/HCPCS | Primary Procedure Code (entered by provider) |
| Modifier | Modifier for procedure code |
| ICD-10 | Diagnosis Code (entered by provider) |
| CPT/HCPCS | Additional Procedure Code (entered by provider) |
| Modifier | Modifier for additional procedure code |
| ICD-10 | Diagnosis Code (entered by provider) |
Provider Actions and Submission Requirements
Prior Authorization Data Elements Required
Prior Authorization Required: Providers must submit the outpatient prior authorization form including the *primary procedure code (CPT/HCPCS), diagnosis code (ICD-10), start/admission and end/discharge dates (MMDDYYYY), and total units/visits/days*. Ensure ALL required fields are completed; incomplete forms will be rejected.
- Enter the outpatient service type number (e.g., 199 Adult Day Care; 422 Biopharmacy; 712 Cochlear Implants & Surgery; 299 Drug Testing; 922 Experimental and Investigational Services; 205 Genetic Testing & Counseling; 290 Hyperbaric Oxygen Therapy; 141 Imaging; 112 Nutritional Supplements and/or Services; 279 Occupational Therapy Evaluation; 101 Physical Therapy; 997 Office Visit/Consult; 794 Outpatient Services; 171 Outpatient Surgery; 428 Second Opinion; 201 Sleep Study; 993 Transplant Evaluation; 209 Transplant Surgery; 724 Transportation; 971 Physical Therapy Evaluation (nonpar only); 127 Speech Therapy Evaluation (nonpar only); 701 Speech Therapy; 790 Occupational Therapy).
- Provide primary and any additional procedure codes with modifiers as applicable.
- Include diagnosis code(s) (ICD-10) and the required dates in MMDDYYYY format (Start/Admission and End/Discharge).
- Report total units/visits/days for the requested authorization period.
Required Supporting Clinical Information
Providers must attach copies of all supporting clinical information. Required supporting documentation may include, but is not limited to: clinical notes, relevant imaging or test results, evaluation reports (e.g., PT/OT/Speech evaluations), operative reports, and any other documentation that supports medical necessity. Lack of clinical information may result in delayed determination.
- All supporting clinical information copies are required — submissions without supporting documentation may be delayed or denied.
- Ensure documentation corresponds to the codes, dates, and requested services on the form.
Form Completeness and Supporting Documentation
Form completeness and timely supporting documentation are enforced. ALL required fields must be filled; incomplete forms will be rejected. An authorization decision may be delayed if clinical information is insufficient. Note: an authorization is not a guarantee of payment — member eligibility, benefit coverage, and medical necessity at the time of service determine payment.
- Incomplete forms will be rejected — double-check required fields before submission.
- An authorization is not a guarantee of payment; verify member eligibility and benefit coverage at time of service.
Additional Provider Actions / Form Instructions
Additional provider action: Enter the Service type number in the designated boxes on the form and include purchase price when selecting DME Purchase. Follow confidentiality and HIPAA requirements when transmitting patient information.
- For DME, indicate whether Rental (417) or Purchase (120) and provide Purchase Price if applicable.
- Enter the correct outpatient service type number in the form's service type field.
- Protect PHI when sending documents; if received in error, notify and destroy per instructions.
Transplant Evaluation Requirements
Transplant evaluation requires prior authorization
For transplant evaluation requests, select the Transplant Evaluation service type (993) on the form and submit the prior authorization with the required supporting clinical documentation.
- Enter service type number 993 for Transplant Evaluation
- Attach all supporting clinical information as required
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