CurrentmhnPolicy N/A

Medicare outpatient prior authorization request form/process

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.

Policy Summary

Payermhn

PolicyMedicare outpatient prior authorization request form/process

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionFax the completed standard or expedited outpatient authorization form to 844-501-5713 (use separate fax numbers for transplant or behavioral health) and include all required fields and supporting clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7 daysstandard determination timeframe from receipt

physician signature requiredfor expedited requests

844-501-5713fax number for standard/expedited requests

833-769-1143fax number for transplant requests

855-663-2244fax number for behavioral health requests

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Submission and Coverage Criteria

Submission and documentation criteria

Operational and submission criteria for prior authorization requests.

All required fields on the outpatient authorization form must be completed; incomplete forms will be rejected.

From form: incomplete forms rejected; copies of supporting clinical information required.

Copies of all supporting clinical information must be included with the request; lack of clinical information may delay determination.

Supporting clinical information required to avoid delays.

Include member information: member name, date of birth (MMDDYYYY), and Member ID.

Include requesting provider information: contact details, NPI/TIN, phone, and address.

Include servicing provider information or indicate same as requesting provider: contact details, NPI/TIN, phone, and address.

Provide authorization request details: primary and additional procedure codes (CPT/HCPCS) and modifiers, diagnosis code (ICD-10), start/admission and end/discharge dates (MMDDYYYY), and total units/visits/days.

Select the outpatient service type from the form's enumerated list (includes imaging, outpatient surgery, therapy, transplant services, behavioral health categories, DME, etc.).

Submission: Fax the completed form to the appropriate fax number depending on request type: standard/expedited fax 844-501-5713; transplant fax 833-769-1143; behavioral health fax 855-663-2244.

Use the fax number for the specific request type.

Timing and expedited processing: Determinations are made as expeditiously as the enrollee's condition requires; standard determinations no later than 7 calendar days after receipt. Expedited requests must be signed by the physician and are processed faster when waiting could seriously jeopardize the enrollee's life, health, or ability to regain maximum function.

Expedited requests require physician signature.

Authorization notice: An authorization is not a guarantee of payment; member eligibility and medical necessity at time of service still apply.

Procedure, Diagnosis and Timing Fields

Procedure and diagnosis codesmixed

CPT/HCPCS	Primary and additional procedure codes and modifiers to be supplied by requesting provider
ICD-10	Diagnosis code required

Timing and utilization fields (format requirements)

Required date fieldsStart/Admission Date and End/Discharge Date must be provided in MMDDYYYY format

Total utilizationTotal Units/Visits/Days must be provided

Procedure/diagnosis linkageEnter associated procedure codes (CPT/HCPCS) and diagnosis code (ICD-10) with the dates

Form Submission, Documentation, and Required Fields

Prior Authorization

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

Documentation Required

Form completeness and supporting documentation

Key Definitions and Disclaimers

Expedited request — definition and requirements

DefinitionAn expedited request is made when the enrollee or the enrollee's physician believes waiting for a standard decision could place the enrollee's life, health, or ability to regain maximum function in serious jeopardy

Physician attestationExpedited requests must be signed by the physician to receive priority

Decision timeframeDeterminations for expedited requests are made as expeditiously as the enrollee's condition requires (faster than standard)

Authorization disclaimer and related notices

Payment disclaimerAuthorization is not a guarantee of payment; member must be eligible at the time services are rendered and services must be covered and medically necessary

Documentation requirement

Billing Rule

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)