Get Established Ccs/ghpp Client Service Authorization Request (sar)

Completing the established CCS/GHPP client service authorization request (SAR) online can be a straightforward process with the right guidance. This guide provides clear instructions to assist you in accurately filling out each section of the form to avoid any delays in service authorization.

Follow the steps to complete the form effectively.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the date of your request in the appropriate field, indicating when you are submitting the form.
3. Provide your provider information by entering your name, Medi-Cal provider number, address, contact person, contact telephone number, and fax number where indicated.
4. Next, fill in the client information. Enter the client's last name, first name, and middle name. Indicate the gender by marking the correct box and record the client's date of birth, CCS/GHPP case number, client index number (CIN), and client’s Medi-Cal number.
5. For the diagnosis section, enter the diagnosis or ICD-9 code related to the requested services, if known.
6. In the requested services section, check the appropriate box for the type of service authorization request you are making—either a new SAR or an authorization extension. If requesting an extension, enter the previous authorization number.
7. Provide the CPT-4, HCPCS code, or NDC code for the service being requested, if applicable, along with a specific description of the procedure/service and the desired dates for service.
8. Indicate the frequency or duration of the requested services, the quantity, and units of service if applicable, especially for pharmacy claims.
9. Check if any additional documentation is included and ensure to enter the facility name where services will be provided, if different from your office.
10. For inpatient hospital services, complete the relevant fields including begin date, end date, number of days, and any extension information required.
11. In the additional services requested section, provide the necessary details for any other health care providers involved, including their name, Medi-Cal provider number, contact information, and a description of their services.
12. Lastly, ensure the form is signed by the physician or authorized representative and enter the date the form is being signed. Review all entries for accuracy before submission.

Complete your documents online efficiently and ensure timely service authorization.