24-027m Follow Prior Authorization Requirements to Submit Palliative Care Requests
Date: 01/02/24
Confirm diagnosis for advanced acute illness to receive palliative care
Palliative care is available to eligible Medi-Cal members (including those enrolled Dual Special Needs Plans (D-SNPs)) at any age while they receive covered benefits and services if they meet all the criteria. To view the complete list of criteria, please go to the Palliative Care section of the Medi-Cal Provider Operations Manual in the Provider Library.
Submit a prior authorization request with medical records
Once the need for palliative care has been determined, you must fill out a prior authorization request. Submit the request with the member’s medical records that relate to the advanced acute illness.
| Type of Request | Time |
|---|---|---|
Response time to requests | Standard | 5 business days |
Urgent | 72 hours |
Access the request form online
The Outpatient California Medi-Cal Prior Authorization form can be filled out online and faxed with the medical records. Or print the form, fill it out and fax the information. The form is available in the Provider Library under Forms and References.
Include diagnosis, procedure code and units
The following information is required and must be included on the request for the prior authorization to process correctly.
Description | Code/Units |
|---|---|
Diagnosis code | Z51.5 |
Procedure code | S0311 |
Units | 6 (equals 6 months) |
Choose a contracted provider
A list of contracted providers for hospice care titled Palliative Care Contracted Providers is available in the Provider Library under Forms and References. You must select a provider from the list and add it to the request form under ‘Servicing Provider’ before submitting the form.
Fax forms and medical records
After completing the request form and adding the related medical records, fax the information to 800-743-1655. For transplants, fax to 833-769-1141. The fax numbers are also found at the top of the Outpatient California Medi-Cal Prior Authorization form.
Additional information
Relevant sections of Health Net’s provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library on Health Net’s provider portal.
If you have questions regarding the information contained in this update, contact the Health Net Medi-Cal Provider Services Center at 800-675-6110.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.
For Medi-Cal, this information applies to Amador, Los Angeles, Calaveras, Sacramento, Inyo, Mono, San Joaquin, Stanislaus, Tuolumne, and Tulare counties.