Prior Authorization Request Form - L.A. Care Health Plan

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AUTHORIZATION IS CONTINGENT UPON MEMBER’S ELIGIBILITY ON DATE OF SERVICE. REV 11/20. Do not schedule non-emergent services until authorization is obtained . LA2629 12/19 *CPT / HCPCS Codes / Descriptions for service(s) REQUIRING Authorization . In-Network Specialty Referrals DO NOT require prior Auth

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