Medicare outpatient prior authorization request form/process
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Governance of outpatient prior authorization requests for Medicare members of Health Net California, including standard and expedited request workflows, required fields, and submission instructions; applies to providers requesting outpatient authorizations in California.
No material clinical or coverage changes in this revision.
Submission and Coverage Criteria
Submission and documentation criteria
Operational and submission criteria for prior authorization requests.
From form: incomplete forms rejected; copies of supporting clinical information required.
Supporting clinical information required to avoid delays.
Use the fax number for the specific request type.
Expedited requests require physician signature.
Procedure, Diagnosis and Timing Fields
| CPT/HCPCS | Primary and additional procedure codes and modifiers to be supplied by requesting provider |
| ICD-10 | Diagnosis code required |
Form Submission, Documentation, and Required Fields
Submission and timing requirements
For standard outpatient prior authorization requests, complete the Medicare Outpatient Authorization form and fax it to 844-501-5713. For transplant and behavioral health requests, use the separate fax numbers listed on the form: Transplant Requests Fax: 833-769-1143; Behavioral Health Requests Fax: 855-663-2244. Expedited requests must be signed by the physician and will be processed as quickly as the enrollee's condition requires, but no later than 72 hours after receipt. Standard requests will be processed within 7 calendar days of receipt.
- Standard fax: 844-501-5713
- Transplant fax: 833-769-1143
- Behavioral Health fax: 855-663-2244
- Expedited requests require physician signature and are handled within 72 hours
- Standard requests adjudicated within 7 calendar days
Form completeness and supporting documentation
All required fields on the form must be completed. Incomplete or missing information will result in the form being rejected. Copies of all supporting clinical documentation (e.g., clinical notes, test results, operative reports, imaging, prior treatment history) must be attached; lack of clinical information may delay the determination. An authorization decision is not a guarantee of payment — eligibility, benefit coverage, and medical necessity will be verified at time of service.
- Complete every field marked with an asterisk (*)
- Attach copies of supporting clinical information — incomplete documentation may delay or result in denial
- Expedited request must be signed by the physician to receive priority
Required clinical and billing information on form
Enter required clinical and billing details directly on the authorization form: primary and any additional procedure codes (CPT/HCPCS) and modifiers, diagnosis code(s) (ICD-10), start/admission and end/discharge dates (MMDDYYYY), and total units/visits/days requested. Select the appropriate Outpatient Service Type number from the list on the form (examples include Physical Therapy 101, Occupational Therapy 790, Outpatient Surgery 171, Transplant Evaluation 993, Behavioral Health service codes, DME rental/purchase codes, etc.).
- Primary Procedure Code (CPT/HCPCS) and Modifier
- Additional Procedure Codes (CPT/HCPCS) and Modifiers as needed
- Diagnosis Code (ICD-10)
- Start Date or Admission Date (MMDDYYYY) and End Date or Discharge Date (MMDDYYYY)
- Total Units/Visits/Days
- Select Outpatient Service Type number (consult form list)
Key Definitions and Disclaimers
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.