[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288904-105":53,"doc-detail-288904-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","pl-1798-0124-prior-authorization-fax-request-form","PL 1798 0124 - Prior Authorization Fax Request Form","","Prior Authorization Fax Request Form (and referral form for the L.A. 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Care Direct Network referrals when prior authorization is not required for that referral, including standing referrals under the stated conditions.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What fax numbers and request routing are listed on the form?",{"text":113,"@type":109},"The form lists routine/post service and urgent fax numbers, plus a separate Behavioral Health fax, Community Based Adult Services fax, LTC/SNF/ICF fax, and additional specialty-related fax numbers.",{"name":115,"@type":106,"acceptedAnswer":116},"What information is required to complete the clinical portion of the request?",{"text":117,"@type":109},"Submit CPT/HCPCS codes with quantity and describe clinical indications, including pertinent past medical treatment and physical findings, and attach all relevant medical records. 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Care Direct Network Only) |  |  |  |  |  |  | |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| If you are a PCP or Specialist requesting a referral to an In-Network Provider, mark the box above for Referral Form there is NO PRIOR AUTH REQUIRED for this referral. Fax a copy of this Referral and your Clinical notes to the In-Network Servicing Provider to notify them of your Referral and direct your patient to call for an appointment.\u003Cbr>☐ Referral Form for Standing Referrals (L.A. Care Direct Network Only)\u003Cbr>Standing referrals may be needed for members with a condition that requires specialized care over an extended amount of time. If you are a PCP or Specialist requesting a standing referral to an In-Network Provider, mark the box above for Referral Form for Standing Referrals. NO PRIOR AUTH REQUIRED for these services.\u003Cbr>FAX this referral along with clinical notes to the In-Network Servicing Provider AND to L.A. Care at 213-438-5777 |  |  |  |  |  |  |  |\n| Outpatient and Elective Services\u003Cbr>Routine / Post Service Fax: 213.438.5777 / Urgent Fax: 213.438.6100 |  |  |  |  |  | Behavioral Health Fax: 213-438-5054 |  |\n| ☐ Acupuncture ☐ Chiropractic ☐ Clinical Trials\u003Cbr>☐ DME/Supplies\u003Cbr>☐ Home Health | ☐ Hospice\u003Cbr>☐ IP Surgery\u003Cbr>☐ Laboratory / Pathology\u003Cbr>☐ OP Surgery\u003Cbr>☐ Palliative Care | ☐ Pharmacy\u003Cbr>☐ Private Duty Nursing\u003Cbr>☐ Prosthetics\u003Cbr>☐ PT / OT / ST\u003Cbr>☐ Radiology |  | ☐ Specialty Referral ☐ Transgender Services ☐ Transplant Eval to Surgery |  | ☐ BH Therapy / ASD |  |\n|  |  |  |  |  |  | CBAS Fax: 213-438-5739 |  |\n|  |  |  |  |  |  | ☐ Community Based Adult Services |  |\n| LTC / SNF / ICF Fax: 213-438-4877 |  |  |  |  |  | Transportation Fax: 213-438-2201 |  |\n| PASRR results required for: ☐ Long Term Care\u003Cbr>PASRR results not required for: ☐ ICF/DD |  |  | ☐ Subacute Care – Adults\u003Cbr>☐ ICF/DD-H |  | ☐ Subacute Care – Pediatrics\u003Cbr>☐ ICF/DD-N | ☐ Non-Emergency Medical Transport |  |\n\nNot sure whether service requires prior authorization? Use our code look-up tool [https://www.lacare.org/providers/provider-resources/prior-authorization-search](https://www.lacare.org/providers/provider-resources/prior-authorization-search)[ ](https://www.lacare.org/providers/provider-resources/prior-authorization-search)Any questions? Call the L.A. Care UM Call Center at 877.431.2273 Complete *BOLDED required fields below to avoid delays in processing  \n\n| Member Information |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| *Member ID: |  |  | *Date of Birth: / / |  |\n| *Member Name: |  |  |  |  |\n| Requesting Provider Information |  |  |  |  |\n| To find an in-network Provider please visit [http://www.lacare.org/find-doctor-or-hospital](http://www.lacare.org/find-doctor-or-hospital) |  |  |  |  |\n| *Request Date: / / *Request Type: ☐ Routine ☐ Urgent ☐ Post Service |  |  |  |  |\n| *Requesting Provider: *NPI: |  |  |  |  |\n| *Phone Number: *Fax Number: |  |  |  |  |\n| *Address: *City: *Zip: |  |  |  |  |\n| *Starting Service Date: / / |  | *Ending Service Date: / / |  |  |\n| Servicing Provider Information |  |  |  |  |\n| *Servicing Provider: *NPI: |  |  |  |  |\n| *Phone Number: *Fax Number: *Specialty: |  |  |  |  |\n| *Address: *City: *Zip: |  |  |  |  |\n| *Place of Service: ☐ Office ☐ Home ☐ Inpatient ☐ Outpatient ☐ Other: |  |  |  |  |\n| Facility Provider Information (if applicable) |  |  |  |  |\n| *Servicing Facility: *NPI: |  |  |  |  |\n| *Phone Number: *Fax Number: |  |  |  |  |\n| *Address: *City: *Zip: |  |  |  |  |\n| *List ICD-10 Codes: |  |  |  |  |\n|  |  |  |  |  |\n| *CPT / HCPCS Codes for requested service(s) including Quantity: Describe clinical Indications & include pertinent past medical treatment, physical findings and attach all relevant medical records. |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n| Is the service being requested Out of Network? ☐ No ☐ Yes If yes, please provide reason for Out ","cbCaic15KRB0xs8N","https://ap.wps.com/l/cbCaic15KRB0xs8N","pdf",176223,8,"English","# Submission Instructions\n## Referral Options and Fax Routing\n# Member and Provider Information\n## Required Fields\n# Clinical Coding and Request Details\n## Out-of-Network Reason\n## Certification and Eligibility Note","[{\"question\":\"When is a referral form used instead of prior authorization for this request?\",\"answer\":\"Use the referral form for L.A. Care Direct Network referrals when prior authorization is not required for that referral, including standing referrals under the stated conditions.\"},{\"question\":\"What fax numbers and request routing are listed on the form?\",\"answer\":\"The form lists routine/post service and urgent fax numbers, plus a separate Behavioral Health fax, Community Based Adult Services fax, LTC/SNF/ICF fax, and additional specialty-related fax numbers.\"},{\"question\":\"What information is required to complete the clinical portion of the request?\",\"answer\":\"Submit CPT/HCPCS codes with quantity and describe clinical indications, including pertinent past medical treatment and physical findings, and attach all relevant medical records. ICD-10 codes are also requested.\"}]","PL 1798 0124 - Prior Authorization Fax Request Form | PDF",1789634192]