Community Health Plan of Imperial Valley – Prior Authorization Request Form – Inpatient Form

INPATIENT CALIFORNIA MEDI-CAL PRIOR AUTHORIZATION
Complete and Fax to: 800-743-1655 X Standard requests. Determination within the lesser of five business days or seven calendar days of receiving all necessary information. 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. URGENT REQUESTS MUST BE SIGNED BY THE PHYSICIAN TO RECEIVE PRIORITY

• INDICATES REQUIRED FIELD 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) Discharge Date (if applicable) otherwise Length of Stay will be based on Medical Necessity (MMDDYYYY) Additional Diagnosis Code (ICD-10) INPATIENT SERVICE TYPE (Enter the Service type number in the boxes) Delivery 779 C-Section Delivery 720 Vaginal Delivery Inpatient Rehab 427 Rehab Transplant 992 Transplant Miscellaneous 970 Medical 414 Premature/False Labor 402 Skilled Nursing Facility 411 Surgical 492 Subacute 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: Disclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered benefit and medically necessary with prior authorization as per the Plan
  policy and procedures. Community Health Plan of Imperial Valley (“CHPIV”) is the Local Health Authority (LHA) in Imperial County, providing services to Medi-Cal enrollees in Imperial County. CHPIV contracts with Health Net Community
  Solutions, Inc. to arrange healthcare services for CHPIV enrollees. Health Net Community Solutions, Inc. is a subsidiary 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-6082 6082
  SIGN