Administrative Days Authorization Request Form Form

ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED & RETURNED. OPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION Disclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Benefit and medically necessary with prior authorization as per Plan policy and procedures. Confidentiality: The information contained in this transmission is confidential and may be protected under the Health Insurance Portability and Accountability Act of 1996. If you are not the intended recipient any use, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and destroy this document. Rev 06112025
Administrative Days Authorization Request Form Visit the provider portal to submit initial authorization requests online at https://countycare.valence.care Fax completed form to Medical:1-800-856-9434 BH/SUD: 1-800-498-8217 Phone number: 1-855-444-1661

• = Required Information REQUESTS SHOULD BE PROVIDED WITHIN 2 BUSINESS DAYS FROM DATE OF ADVERSE DETERMINATION. RETRO REQUESTS WILL BE CONSIDERED BUT MUST CONTAIN CLEAR DOCUMENTATION OF SUBSTANTIAL DISCHARGE BARRIERS TO BE CONSIDERED. Requestor’s Contact Name: Requestor’s Contact Number: PATIENT INFORMATION Member Name: Date of Birth: Member ID Number: Member Phone Number: SERVICE TYPE ☐Inpatient Mental Health/Detox ☐Inpatient Medical PROCEDURE INFORMATION ICD-10 Diagnosis: Diagnosis Description: CPT Code:__ Units: ____ Requested Start Date: ___ PROVIDER INFORMATION Ordering Provider: Primary Care Physician Name: NPI: TIN: Fax: Phone Address: Servicing Provider: Same as Ordering Name: NPI: TIN: Fax: Phone Address: Facility: N/A Name: NPI: TIN: Fax: Phone Address: Page 1

Administrative Days Authorization Request Form Visit the provider portal to submit initial authorization requests online at https://countycare.valence.care ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED & RETURNED. COPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION Disclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Benefit and medically necessary with prior authorization as per Plan policy and procedures. Confidentiality: The information contained in this transmission is confidential and may be protected under the Health Insurance Portability and Accountability Act of 1996. If you are not the intended recipient any use, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and destroy this document. Rev 06112025 CARE COORDINATION UR Department Discharge Planner Health Plan Care Coordinator ☐ N/A ☐ N/A ☐ N/A Name: Name: Name: Phone: Phone: Phone: Fax: Fax: Fax: Email: Email: Email: REASON THE MEMBER CANNOT RETURN TO THEIR PREVIOUS PLACEMENT CLINICAL INFORMATION Please provide a summary of daily discharge planning activities, barriers to transition and efforts to overcome these, including names and dates of facilities or providers the case has been referred to and the outcomes of those referrals, patient/family decisions around discharge planning options, and any other circumstances around discharge planning. Additional information may be needed in ordered to process your request. If we are unable to obtain additional information, it will impact processing. Please do NOT attach clinical. Provide summary below.