Medi-Cal – Prior Authorization Request Form – Outpatient Form

OUTPATIENT CALIFORNIA HEALTH NET MEDI-CAL AUTHORIZATION FORM
Complete and Fax to: 800-743-1655 Transplant Fax: 833-769-1141 Request for additional units Existing Authorization Units Standard requests: Determination made as expeditiously as the enrollee’s health condition requires, but no later than the lesser of five business days or seven calendar days after the receipt of request. Urgent requests: I certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within
72 hours to avoid complications and unnecessary suffering or severe pain.

• INDICATES REQUIRED FIELD X URGENT REQUESTS MUST BE SIGNED BY
  THE PHYSICIAN TO RECEIVE PRIORITY MEMBER INFORMATION Last Name, First Date of Birth (MMDDYYYY) Member ID REQUESTING PROVIDER INFORMATION Requesting Provider Contact Name Requesting NPI Requesting TIN Phone Requesting Provider Address Fax City, State, ZIP SERVICING PROVIDER / FACILITY INFORMATION Same as Requesting Provider Servicing Provider Contact Name Servicing NPI Servicing TIN Phone Servicing Provider/Facility Name Address Fax City, State, ZIP AUTHORIZATION REQUEST Primary Procedure Code (CPT/HCPCS) (Modifier) Additional Procedure Code (CPT/HCPCS) (Modifier) Start Date OR Admission Date (MMDDYYYY) Diagnosis Code (ICD-10) Additional Procedure Code (CPT/HCPCS) (Modifier) Additional Procedure Code (CPT/HCPCS) (Modifier) End Date OR Discharge Date (MMDDYYYY) Total Units/Visits/Days OUTPATIENT SERVICE TYPE (Enter the Service type number in the boxes)
  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 DME
  417 Rental
  120 Purchase
  (Purchase Price) ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED.
  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.*Health Net of California, Inc. and Health Net Community Solutions, Inc. are subsidiaries of Health Net, LLC and Centene Corporation. Health Net is a registered service mark of Health
  Net, LLC. All other identified trademarks/service marks remain the property of their respective companies. All rights reserved.
  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. 05 15 2026 XC-PAF-6083 6083 SIGN

Outpatient Authorization Supplemental Form
This page is optional and meant to be used when an authorization request exceeds more than four (4) Procedure Codes. When applicable, please submit this form with the Outpatient Prior Authorization Form to the applicable fax number.

• INDICATES REQUIRED FIELD MEMBER INFORMATION *Date of Birth (MMDDYYYY)
• Medicaid/Member ID Last Name, First AUTHORIZATION REQUEST
  Additional Procedure Code Start Date OR Admission Date *End Date Total Units/Visits/Days Additional Procedure Code Start Date OR Admission Date End Date Total Units/Visits/Days Additional Procedure Code Start Date OR Admission Date End Date Total Units/Visits/Days Additional Procedure Code Start Date OR Admission Date End Date Total Units/Visits/Days Additional Procedure Code Start Date OR Admission Date End Date Total Units/Visits/Days Additional Procedure Code Start Date OR Admission Date End Date Total Units/Visits/Days Additional Procedure Code Start Date OR Admission Date End Date Total Units/Visits/Days Additional Procedure Code Start Date OR Admission Date End Date Total Units/Visits/Days Additional Procedure Code Start Date OR Admission Date End Date Total Units/Visits/Days Additional Procedure Code Start Date OR Admission Date End Date Total Units/Visits/Days 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.