CurrentmhnPolicy N/A

Inpatient California Health Net Medi-Cal Prior Authorization

This document governs the prior authorization request process for inpatient services under Health Net California Medi-Cal and affects requesting and servicing providers/facilities and members requiring inpatient authorization.

Policy Summary

Payermhn

PolicyInpatient California Health Net Medi-Cal Prior Authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed inpatient prior authorization form with all required fields and supporting clinical information; fax to 1-800-743-1655.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysDetermination timeframe after receiving all necessary information

72 hoursUrgent request response window

1-800-743-1655Fax number to submit completed form

Rev. 06092021Form revision date

Coverage Preconditions and Criteria

Coverage Preconditions

Coverage is conditional on member eligibility and medical necessity; prior authorization is required and must include supporting clinical documentation.

Prior authorization is required before inpatient services will be considered for coverage; complete the inpatient prior authorization form and submit as directed.

ALL of the following

Member must be eligible at the time services are rendered.
Services must be a covered Health Plan benefit and medically necessary.

Copies of all supporting clinical information are required. Lack of clinical information may result in delayed determination or rejection of the request.

Policy Summary

Payermhn

PolicyInpatient California Health Net Medi-Cal Prior Authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed inpatient prior authorization form with all required fields and supporting clinical information; fax to 1-800-743-1655.

SourceLink

On This Page

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Submission Steps, Timelines, and Notices for Providers

Prior Authorization

Prior Authorization Submission and Timelines

Submit a completed inpatient prior authorization form with all required fields and supporting clinical information. Incomplete forms or missing clinical documentation will be rejected or cause delays. Copies of all supporting clinical information are required.

Complete all required fields (Member ID, DOB, admission/start date, discharge date or length of stay, diagnosis codes, requesting and servicing provider NPI/TIN).
Fax completed form and supporting clinical documentation to 1-800-743-1655.
Determinations: standard requests — within 5 business days of receiving all necessary information; urgent requests — physician-signed and handled per urgent timelines (e.g., within 72 hours when applicable).
Ensure Urgent requests are signed by the physician to receive priority.
Indicate admission/start and discharge dates in MMDDYYYY format where requested.

Denial Risk

Authorization Disclaimer

An authorization is not a guarantee of payment. Verify member eligibility and benefits at the time services are rendered. Services must be covered, medically necessary, and in accordance with Plan policy and procedures to be payable.

Authorization only indicates that services were approved based on information available at the time of review — payment is subject to member eligibility and coverage at date of service.
Confirm member eligibility and any benefit limitations on the date of service prior to rendering care.

Key Terms and Definitions

Urgent request — definition/summary of urgent request handling

DefinitionAn urgent request is a prior authorization request certified by the requester as urgent and medically necessary to treat an injury, illness, or condition (non–life-threatening) that requires a determination within 72 hours to avoid complications, unnecessary suffering, or severe pain.

Response timeframeDetermination provided within 72 hours for urgent (non–life‑threatening) requests to avoid complications.

Request certificationRequest must be certified by the requester as urgent and medically necessary to qualify for the expedited 72‑hour review window.

ScopeApplies to inpatient prior authorization requests using the Health Net California Medi‑Cal inpatient prior authorization form.

Authorization (not guarantee of payment) — definition/summary

DefinitionAn authorization is a decision that a requested service meets prior authorization criteria but is not a guarantee of payment; member eligibility, coverage as a Health Plan Benefit, and medical necessity at the time services are rendered are required for payment.

Payment caveatAuthorization does not guarantee payment — member must be eligible at time of service and service must be a covered Health Plan Benefit and medically necessary.

Related requirementsServices must have prior authorization per Plan policy and procedures; authorization reflects only that prior‑authorization criteria were met at time of review.

Submission contextStatement appears on the inpatient authorization request form and applies to Health Net of California and its subsidiaries.

720	Vaginal Delivery (service type code)
779	C-Section Delivery (service type code)
427	Inpatient Rehab (service type code)
992	Transplant (service type code)

970	Medical
414	Premature/False Labor
402	Skilled Nursing Facility
411	Surgical
492	Subacute

OpenPayer

Inpatient California Health Net Medi-Cal Prior Authorization

Coverage Preconditions and Criteria

Service Types and Procedure Codes

Submission Steps, Timelines, and Notices for Providers

Key Terms and Definitions