21-442 Know the Requirements for Prior Authorization Requests
Date: 07/19/21
Requests are faxed back for missing information starting August 1, 2021
You can help get your prior authorization requests processed faster. Check that you include all information when you fax requests, know what qualifies as an urgent request and learn how to prevent duplicate submissions.
Use the checklist before you fax
Include all information on this checklist when you fax a request for prior authorization:
- Diagnosis code.
- Procedure code.
- Requesting provider’s National Provider Identifier (NPI).
- Requesting provider’s Tax Identifier Number (TIN).
- Anticipated service start date or admission date.
- Servicing provider’s NPI.
- Servicing provider’s TIN.
Action required for returned requests
Starting August 1, 2021, your faxed prior authorization request will be faxed back to you if it is missing any information that is on the checklist. The returned fax will state what information is missing so you can resubmit it for review. This process will increase efficiency and timely processing of the requested authorization.
What qualifies as urgent
Requests marked urgent with a date of service more than 10 days from the request date will be downgraded from an urgent to a standard request. The decision will be made according to the standard timeframe (5 business days of receipt of all necessary information).
The health plan uses the definitions below to classify urgent utilization management requests:
- Urgent Request: A request for medical care or services where application of the timeframe for making a routine or non-life threatening care determinations:
- Could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on a prudent layperson’s judgment, or
- Could seriously jeopardize the life, health or safety of the member or others, due to the member’s psychological state, or
- In the opinion of a practitioner with knowledge of the member’s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is the subject of the request.
Urgent requests must be submitted and signed in accordance to the Health and Safety Code (HSC 1367.01) and APL 17-006. Regulations are available upon request.
Avoid duplicate submissions
The Prior Authorization Department is experiencing an influx of duplicate submission faxes from providers. Below are some key reminders:
- Refer to the Prior Authorization List or check the Code Checker Tool located in the provider portal prior to faxing a request to ensure a prior authorization is required. We see many requests for services that do not require prior authorization.
- If you get a confirmation that we have received the fax, please do not resubmit for follow-up status. Multiple submissions may delay processing.
- Allow a reasonable amount of time to receive your fax confirmation.
NOTE: If a request was previously denied, please follow the appeal process as indicated on the denial letter. Any requests resubmitted after the authorization has been denied will be returned with instructions to follow the appeal process.
Prior authorization contact information
Use the contact information below to call, fax or access the provider portal:
Phone: 877-658-0305
Fax: 866-724-5057
Additional information
Providers are encouraged to access California Health & Wellness Plan’s (CHWP’s) provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CHWP at 877-658-0305.