REVISED ICD10 FORMS MANAGED LONG TERM SERVICES AND SUPPORTS AUTHORIZATION REQUEST FORM Please fax completed form to appropriate L.A. Care UM Department fax number listed below: LONG TERM CARE: (213) 4384877 COMMUNITY BASEDADULT SERVICES: (213) 4385739 If the treating physician would like to discuss this case with the physician or health care professional reviewer or obtain a copy of the criteria used to make this decision, please call 18774312273. Rev. 08.11.15 AUTHORIZATION IS CONTINGENT UPON MEMBER’S ELIGIBILITY ON DATE OF SERVICE Do not schedule nonemergent requested service until authorization is obtained. PL0022b 08/15 REQUEST INFORMATION Request Date: Request Type (check one) Preservice Urgent Post Service Routine Line of Business (check one): MCLA Cal MediConnect PCP: PPG: PATIENT INFORMATION Member Name: Date of Birth: Preferred Language: Member ID/SSN: Address: City: Zip: Phone: Patient’s Authorized Representative (if any): Alternate Phone: REQUEST – SERVICE TYPE REQUESTED MLTSS – SERVICE TYPE REQUESTED CBAS Face to Face Assessment (CEDT) SNF – LONG TERM CARE CBAS 3Day Assessment for IPC development LTC Initial services CBAS Initial services (must include IPC) LTC Reauthorization CBAS Continuation of services (same level) LTC Bed Hold/Leave of absence CBAS Modification of continued services LTC Subacute CBAS Reinstatement of services CBAS Transfer of services PROVIDER SUBMITTING REQUEST / FACILITY SUBMITTING REQUEST Requesting Provider Name: Specialty: Phone Number: Fax Number: Address: City: Zip: PROVIDER PERFORMING/PROVIDING SERVICE Requested Provider Name: Specialty: Phone Number: Fax Number: Address: City: Zip: DIAGNOSIS/PROCEDURE INFORMATION Include ICD10 codes on all requests prior to and after 10/1/2015 ICD9 Code(s)/Description (Prior to 10/1/2015): ICD10 Code(s)/Description CPT Code(s)/Description: HCPCS Code(s)/Description: Clinical Indications for request (include pertinent past medical treatment, physical findings and attach all relevant medical records, test results, etc.): Is the service being requested out of network? No Yes If yes, please provide reason for using an out of network facility: Provider Name: (Print) Provider Signature: Date: