[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283871-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283871-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","outpatient-california-healthnet-medicare-authorization-form-completion-and-submission-instructions","Outpatient California HealthNet Medicare Authorization Form - Completion and Submission Instructions","","Outpatient California HealthNet Medicare Authorization Form collects required member, requesting provider, and servicing provider or facility details to request authorization for outpatient services. The form specifies expedited versus standard request handling, including required contact methods and determination timeframes. It includes fields for procedure codes, modifiers, diagnosis code, start and end or admission and discharge dates, and total units. It also notes prerequisites for supporting clinical information, confidentiality obligations, and that authorization does not guarantee payment.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/outpatient-california-healthnet-medicare-authorization-form-completion-and-submission-instructions/283871/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/outpatient-california-healthnet-medicare-authorization-form-completion-and-submission-instructions/283871.png","ImageObject",442,249,{"name":42,"@type":43},"Lute","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-11-03","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",11,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"How are expedited and standard requests handled on this form?","Question",{"text":63,"@type":64},"Expedited requests require calling 1-800-929-929-9224, while standard requests require faxing to 1-844-501-5713. Determinations follow the appropriate timeframe, with expedited requests addressed based on the enrollee’s condition and no later than the standard limit after receipt.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Which information fields are required to avoid rejection?",{"text":68,"@type":64},"The form states that all required fields must be completed; incomplete forms will be rejected. It also requires copies of supporting clinical information.",{"name":70,"@type":61,"acceptedAnswer":71},"What details must be entered for the authorization request?",{"text":72,"@type":64},"Enter primary and additional procedure codes (CPT/HCPCS) with modifiers, diagnosis code (ICD-10), start or admission date, end or discharge date, and total units/visits/days.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283871,1790038085,{"code":4,"msg":82,"data":83},"success",[84,88,93,98,103,108,112,117,122],{"id":55,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":4},137454149569,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","OUTPATIENT CALIFORNIA HEALTHNET  \nMEDICARE AUTHORIZATION FORM  \nExpedited requests: Call 1-800-929-9224  \nStandard Requests: Fax to 1-844-501-5713  \nRequest for additional units. Existing Authorization Units  \nFor Standard requests, complete this form and FAX to 1-844-501-5713. Determination made as expeditiously as the enrollee’s health condition requires, but no later than 14 calendar days after receipt of request.  \nFor Expedited requests, please CALL 1-800-929-9224. Expedited requests are made when the enrollee or his/her physician believes that waiting for a decision under the  \nstandard timeframe could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy.  \n* INDICATES REQUIRED FIELD    \nDate of Birth*  \nMEMBER INFORMATION  \nMember ID* Last Name, First (MMDDYYYY)  \nREQUESTING PROVIDER INFORMATION  \nRequesting NPI* Requesting TIN* Requesting Provider Contact Name  \nRequesting Provider Name Phone Fax*  \nSERVICING PROVIDER / FACILITY INFORMATION  \n Same as Requesting Provider  \nServicing NPI* Servicing TIN* Servicing Provider Contact Name  \nServicing Provider/Facility Name Phone Fax  \nAUTHORIZATION REQUEST  \n*  \nPrimary Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \n*  \nStart Date OR Admission Date  \n(MMDDYYYY)  \nDiagnosis Code*  \n(ICD-10)  \n*1652*  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nEnd Date OR Discharge Date  \n(MMDDYYYY)  \nTotal Units/Visits/Days  \n\n| OUTPATIENT SERVICE TYPE* (Enter the Service type number in the boxes) |  |  |\n| --- | --- | --- |\n| 422 Biopharmacy\u003Cbr>712 Cochlear Implants & Surgery\u003Cbr>299 Drug Testing\u003Cbr>922 Experimental InvestigationalServices\u003Cbr>799 Genetic Counseling\u003Cbr>709 Genetic Testing\u003Cbr>249 Home Health\u003Cbr>290 Hyperbaric Oxygen Therapy\u003Cbr>141 Imaging Services\u003Cbr>395 Infertility Diagnosis or Treatment\u003Cbr>410 Observation | 790 Occupational Therapy\u003Cbr>997 Office Visit/Consult\u003Cbr>794 Outpatient Services\u003Cbr>171 Outpatient Surgery\u003Cbr>202 Pain Management\u003Cbr>101 Physical Therapy\u003Cbr>701 Speech Therapy\u003Cbr>992 Transplant\u003Cbr>724 Transportation\u003Cbr>792 Vendor | DME (Orthotics and Prosthetics)\u003Cbr>417 Rental\u003Cbr>120 Purchase\u003Cbr>(Purchase Price) |\n\nALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED.  \nCOPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION.  \nDisclaimer: 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.  \nConfidentiality: 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 Rev. 11 17 2017  \nintended 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. XE-PAF-1652","cbCaiu89thchANAW","https://ap.wps.com/l/cbCaiu89thchANAW","pdf",83067,"English","# Member Information\n# Requesting Provider Information\n# Servicing Provider / Facility Information\n# Authorization Request\n# Outpatient Service Type\n# Required Submission Notes","[{\"question\":\"How are expedited and standard requests handled on this form?\",\"answer\":\"Expedited requests require calling 1-800-929-929-9224, while standard requests require faxing to 1-844-501-5713. Determinations follow the appropriate timeframe, with expedited requests addressed based on the enrollee’s condition and no later than the standard limit after receipt.\"},{\"question\":\"Which information fields are required to avoid rejection?\",\"answer\":\"The form states that all required fields must be completed; incomplete forms will be rejected. It also requires copies of supporting clinical information.\"},{\"question\":\"What details must be entered for the authorization request?\",\"answer\":\"Enter primary and additional procedure codes (CPT/HCPCS) with modifiers, diagnosis code (ICD-10), start or admission date, end or discharge date, and total units/visits/days.\"}]","Outpatient California HealthNet Medicare Authorization Form - Completion and Submission Instructions | PDF",1789621194]