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Prospect medical group authorization request form pdf

PDF PPG MemberAuthorization Fax Request Form - LA Care Health Plan 2025

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54 votes

The document is a Treatment Authorization Form used to request medical services for a patient. It includes sections for member information, requesting and rendering provider details, diagnosis codes, procedure codes, specific services requested, and medical justification. The form emphasizes the necessity of obtaining an authorization number for payment and outlines the responsibilities of providers regarding patient eligibility.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I get a prior authorization for L.A. Care?

Please contact the L.A. Care Provider Call Center at 1-877-431-2273 if you have any questions.

Does L.A. Care require prior authorization?

Prior authorization is not required for emergency services, urgent care visits, sensitive services (which includes family planning), sexually transmitted disease services, abortion, minor consent services, human immunodeficiency virus (HIV) testing, basic prenatal care services, routine obstetric services, counseling (

How do I submit a prior authorization to Medi-Cal?

Pharmacy providers and prescribers can submit a PA request via fax number 1-800-869-4325 by utilizing the preferred Medi-Cal Rx Prior Authorization Request Form or any of the following approved forms: 50-1, 50-2, 61-211.

What is the fax number for L.A. Care member services?

Completed referral forms can be faxed to the Care Management Department at 213-438-5077 or sent by secure email. For further assistance, please call L.A. Cares Care Management Department at 1-844-200-0104.

What is the fax number for Health Partners prior authorization?

Fax completed forms to: for Medical (952) 853-8713, for Behavioral Health (952) 853-8830.

prospect medical group prior authorization form

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