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Get L.a. Care Health Plan Pre-authorization Request Form - Lacare
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How to use or fill out the L.A. CARE HEALTH PLAN PRE-AUTHORIZATION REQUEST FORM - Lacare online
Filling out the L.A. Care Health Plan Pre-Authorization Request Form is an essential process for users seeking medical services. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.
Follow the steps to fill out the form correctly.
- Press the ‘Get Form’ button to retrieve the form and open it for editing.
- Begin by locating the 'L.A. Care Use Only' section. Enter the UM Database Log ID number, and check the appropriate box for provider status (in-network or out-of-network).
- Fill in the date at the top of the form to indicate when you are submitting the request.
- Complete the 'Patient Information' section by entering the member's name, date of birth, member ID or social security number, address, and phone number.
- Indicate the urgency of the service by checking one of the options: urgent (within 72 hours), routine (within 5 calendar days), or post service (within 30 calendar days).
- In the 'Referral – Service Type Requested' section, select the appropriate service needed and provide any expected duration if applicable.
- Enter the requesting provider's information including their name, specialty, phone number, address, and fax number.
- Then, fill in the requested provider's information. This is the provider who will perform or provide the service.
- Provide the diagnosis or procedure information by entering the ICD-9 codes, CPT codes, and HCPCS codes as needed. Include descriptions for clarity.
- Describe the clinical indications for the request in detail, including pertinent past medical treatments, physical findings, and attach any relevant medical records as needed.
- Print the requesting provider's name, sign, and date in the designated area to authenticate the request.
- If applicable, in the 'Out-of-Network Request Only' section, include rationale for requesting authorization for services at an out-of-network facility.
- Once the form is completed, save your changes, and prepare to download, print, or share the form as needed.
Complete your L.A. Care Health Plan Pre-Authorization Request Form online today to ensure timely processing.
The GHPP is a prior authorization program. This means that a Service Authorization Request (SAR) must be submitted to the GHPP State office for approval for all diagnostic and treatments services, except for emergencies.