Home>Documents>Healthcare>Authorization Request Form - L.A. Care Health Plan

Authorization Request Form - L.A. Care Health Plan

This file is an authorization request form for the L.A. Care Health Plan. It includes details on how to request prior authorization, urgent care, inpatient care, and other medical services. The form also provides contact information and instructions for completing the request.

Edit, Download, and Sign the Authorization Request Form - L.A. Care Health Plan

Form

eSign

Email

Add Annotation

Share Form

How do I fill this out?

To fill out the authorization request form, you will need to provide various details about the patient, the requesting provider, and the service being requested. Begin by gathering all necessary information, such as patient details, provider details, and clinical indications. Follow the instructions on the form to complete each section accurately.

How to fill out the Authorization Request Form - L.A. Care Health Plan?

1
Download and print the authorization request form.
2
Fill in the patient information, including name, date of birth, and member ID.
3
Provide the details of the requesting and performing providers.
4
Specify the diagnosis/procedure information, including codes and descriptions.
5
Sign and date the form, then fax it to the appropriate L.A. Care UM Department.

Who needs the Authorization Request Form - L.A. Care Health Plan?

1
Healthcare providers seeking prior authorization for services.
2
Physicians requesting urgent or inpatient care authorization.
3
Providers participating in clinical trials requiring authorization.
4
Hospice care providers needing authorization for long-term care services.
5
Transplant specialists requesting evaluation and authorization for transplant services.

How PrintFriendly Works

At PrintFriendly.com, you can edit, sign, share, and download the Authorization Request Form - L.A. Care Health Plan along with hundreds of thousands of other documents. Our platform helps you seamlessly edit PDFs and other documents online. You can edit our large library of pre-existing files and upload your own documents. Managing PDFs has never been easier.

Edit your Authorization Request Form - L.A. Care Health Plan online.

You can easily edit this PDF on PrintFriendly using our PDF editor tool. Simply upload the file, make the necessary changes, and save the updated version. Our editor allows you to modify text, add annotations, and more.

Add your legally-binding signature.

Signing the PDF on PrintFriendly is straightforward. Use our PDF editor to add your digital signature directly to the form. Save and download the signed document for your records.

Share your form instantly.

Sharing the PDF on PrintFriendly is quick and easy. After editing or signing your document, use our sharing options to send the file via email or generate a shareable link. You can also share the document directly on social media platforms.

How do I edit the Authorization Request Form - L.A. Care Health Plan online?

1
Upload the PDF to PrintFriendly.
2
Use the PDF editor to make necessary changes.
3
Add annotations or text as needed.
4
Save the edited version of the PDF.
5
Download the updated document to your device.

What are the instructions for submitting this form?

What are the important dates for this form in 2024 and 2025?

What is the purpose of this form?

Tell me about this form and its components and fields line-by-line.

What happens if I fail to submit this form?

How do I know when to use this form?

What are the instructions for submitting this form?

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.

What are the important dates for this form in 2024 and 2025?

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

What is the purpose of this form?

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.

Tell me about this form and its components and fields line-by-line.

This form contains several fields to capture essential information for the authorization request.

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.

What happens if I fail to submit this form?

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.

How do I know when to use this form?

Use this form when you need to request prior authorization for medical services covered by L.A. Care Health Plan.

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.

Frequently Asked Question

How do I fill out the authorization request form?

Download and print the form, then fill in the required patient, provider, and service information. Sign and date the form, and fax it to the appropriate L.A. Care UM Department.

Can I fill out this form online?

Yes, you can fill out the form online using PrintFriendly's PDF editor. Upload the form, enter the necessary details, and save the completed document.

How do I sign the form on PrintFriendly?

Use PrintFriendly's PDF editor to add your digital signature to the form. Save and download the signed document for submission.

How can I share the filled-out form?

After completing the form, use PrintFriendly's sharing options to send the document via email or generate a shareable link. You can also share it on social media platforms.

What information do I need to fill out the form?

You will need patient information, requesting and performing provider details, and clinical indications for the requested service. Ensure you have all necessary codes and descriptions.

Where do I fax the completed form?

Fax the completed form to the appropriate L.A. Care UM Department based on the type of request. The fax numbers are provided on the form.

Can I save the edited form on PrintFriendly?

Yes, you can save the edited form on PrintFriendly by downloading the updated document after making changes with our PDF editor.

Is there a deadline for submitting the form?

The authorization request form must be submitted before the scheduled date of the non-emergent requested service. Ensure timely submission to avoid delays.

How do I know if the service is out of network?

Check with the service provider or your insurance plan to determine if the requested service is out of network. Provide a reason for using an out-of-network facility if applicable.

Can I use this form for multiple services?

No, each authorization request form should be used for a single service request. Complete separate forms for different services.