Authorization Request Form - L.A. Care Health Plan

To submit the completed authorization request form, fax it to the appropriate L.A. Care UM Department based on the type of request. Prior Authorization: 213.438.5777, Urgent: 213.438.6100, Inpatient: 1.877.314.4957, Delegate Support Team (DST): 213.438.5761, Transplant: 213.438.5071, Medicare: 213.438.5077, L.A. Care Direct Network: 213.438.5680. Ensure that all required fields are accurately filled out and that relevant medical records and test results are attached.

Ensure to submit the authorization request form before the scheduled date of the non-emergent requested service in 2024 and 2025.

The authorization request form is a crucial document for healthcare providers to obtain prior authorization for various medical services from L.A. Care Health Plan. By filling out this form, providers can ensure that their patients receive the necessary care while complying with the health plan's requirements. This form helps streamline the authorization process, reduce delays, and facilitate communication between providers and L.A. Care.

• 1. Request Date: The date on which the request is being made.
• 2. Request Type: Indicates whether the request is urgent or routine.
• 3. Member Name: The name of the member for whom the request is being made.
• 4. Date of Birth: The member's date of birth.
• 5. Member ID: The member's identification number.
• 6. Preferred Written Language: The member's preferred language for written communication.
• 7. Address: The member's address, including city and zip code.
• 8. Phone Number: The member's phone number.
• 9. PCP: The member's primary care physician.
• 10. Line of Business: The type of insurance coverage (e.g., Medi-Cal, Cal MediConnect, L.A. Care Covered, PASC-SEIU).
• 11. Service Type Requested: The specific type of service being requested (e.g., Acute Hospital, Ambulatory Surgery Center, Clinical Trial, Diagnostic Procedure/Radiology).
• 12. Requesting Provider Name: The name of the provider submitting the request.
• 13. Provider Performing/Providing Service: The name of the provider performing or providing the requested service.
• 14. Diagnosis/Procedure Information: Details about the diagnosis or procedure being requested, including ICD-10, CPT, and HCPCS codes.
• 15. Request Status: Indicates whether the request is prior, concurrent, or post-service.
• 16. DME Expected Duration: Estimated duration of Durable Medical Equipment use, if applicable.
• 17. Clinical Indications: Relevant medical treatment history, physical findings, and test results related to the request.
• 18. Out of Network Service: Indicates whether the requested service is out of network and the reason for using an out-of-network facility.

Failing to submit this form can result in delays or denial of the requested service authorization. It is crucial to complete and submit the form accurately and promptly.

• Delays in Service: Without proper authorization, the requested service may be delayed, affecting patient care.
• Denial of Service: Failure to submit the form could lead to denial of the requested service by L.A. Care Health Plan.
• Increased Costs: Patients may incur higher out-of-pocket costs if services are provided without prior authorization.

• 1. Prior Authorization: Requesting prior authorization for planned medical services.
• 2. Urgent Care Authorization: Seeking authorization for urgent medical care.
• 3. Inpatient Care Authorization: Requesting authorization for inpatient hospital services.
• 4. Clinical Trials: Enrolling patients in clinical trials requiring prior authorization.
• 5. Transplant Services: Obtaining authorization for transplant evaluations and procedures.