Filing the CalOptima Prior Authorization Form (ARF): Deadlines and Appeals

The CalOptima prior authorization form comes in two versions, and picking the right one is the first thing that determines whether your request moves or stalls. CalOptima Health, the county organized health system for Orange County, uses an Authorization Request Form (ARF) for medical and surgical services and a separate pharmacy prior authorization form, managed through MedImpact, for prescription drugs. Which form you use, and which fax line you send it to, depends on whether you’re asking for a medical service or a medication, and whether the member is enrolled in Medi-Cal, OneCare (HMO D-SNP), or another CalOptima program.¹

Pick the Right Form First

The ARF covers inpatient admissions, outpatient procedures, specialist consultations, durable medical equipment, and non-emergency medical transportation. CalOptima publishes separate ARF versions for Medi-Cal and for OneCare, so check the member’s enrollment before you download anything.¹

The pharmacy form covers prescription medications that are not on the preferred drug list or that need clinical justification. It routes to MedImpact rather than CalOptima’s own utilization management team.²

Sending a pharmacy request on a medical ARF, or using a Medi-Cal ARF for a OneCare member, puts the paperwork in the wrong queue. The system flags the mismatch immediately and the clock on your decision never really starts.

When Prior Authorization Is Actually Required

Not every service needs advance approval. CalOptima publishes a Prior Authorization Required List of specific procedure codes, updated quarterly for both Medi-Cal and OneCare. Beyond those codes, a few categories always need authorization:¹

Elective services at tertiary care centers, regardless of the procedure code.
All scheduled (non-emergency) inpatient admissions.
Post-stabilization services after an emergency, which require authorization from the Utilization Management department.
Any service from a non-contracted provider.
All “By Report” procedure codes.
Initial specialty consults, which the primary care provider or contracted specialist must authorize before referring.

Wheelchair and hearing aid repairs under $250 are exempt from prior authorization, though standard benefit limits still apply.¹

Completing the Medical ARF

Download the ARF from CalOptima’s provider website or access it through the provider portal at providers.caloptima.org. The form has four sections, and the single most common reason requests get rejected before clinical review is a mismatched or missing identifier.

Patient Information

Enter the member’s full name (last, first), date of birth, gender, age, mailing address, and phone. The critical field is the Client Index Number (CIN), the member’s CalOptima ID. If the member lives in an intermediate care facility or skilled nursing facility, add the facility name.³

Referring and Rendering Provider Information

You need details for two providers: the one making the referral and the one performing the service. For each, enter the name, National Provider Identifier (NPI), Tax Identification Number (TIN), Medi-Cal ID, office address, phone, fax, and an office contact. The referring provider also signs the form. A wrong NPI or TIN causes the system to kick the submission out before a reviewer sees it, so copy these directly from enrollment records rather than typing from memory.³

Diagnosis and Procedure Codes

List the ICD-10 diagnosis code explaining why the service is needed. Then list every requested procedure using CPT or HCPCS codes, with a quantity for each. The quantity field is required. Leaving it blank stops the form at intake. The diagnosis and procedure codes should tell a coherent clinical story; a mismatch between the condition and the requested service is a common reason reviewers return requests for more information.³

Pertinent History and Supporting Records

This is where you make the clinical case. Write a concise summary of the member’s condition, treatments already tried, and why the requested service is necessary. Attach supporting records: recent labs, imaging reports, specialist notes, documentation of failed prior treatments. The reviewing medical director relies on these materials to determine medical necessity. A bare form with no attachments is far more likely to be denied or paused for additional information. Indicate whether the request is inpatient, outpatient, or skilled nursing facility, and include estimated length of stay and dates of service.³

Completing the Pharmacy Form

The MedImpact pharmacy form is shorter but structured the same way. Enter the patient’s name, CalOptima ID, gender, and date of birth, then the prescriber’s name, phone, fax, specialty, NPI, and signature. For the drug, list the name, strength, dosage, and the ICD-10 diagnosis code or a written description of the diagnosis.²

The clinical justification questions matter. The form asks what other medications the patient has tried, why those failed, and why the requested drug is necessary. Answer thoroughly. A one-word reply like “failed” without the drug name, dose, and duration of the prior trial gives the reviewer nothing to work with.

Where to Send the Form

The ARF lists four fax numbers depending on the type of request:³

Routine requests: (714) 246-8579
Retroactive requests: (714) 246-8579
Urgent requests: (714) 338-3137
Physician-administered drugs: (657) 900-1649

You can also submit medical authorizations electronically through providers.caloptima.org. The portal generates a confirmation receipt that serves as your proof of submission and timestamp.

Pharmacy requests go to MedImpact’s fax lines, organized by program:²

Medi-Cal / CalWrap: fax (858) 357-2557 or call (888) 807-5705
OneCare HMO SNP (Medicare Part D): fax (858) 357-2556 or call (800) 819-5532
OneCare Connect: fax (858) 357-2556 or call (800) 819-5480

Keep the fax confirmation page. If a request goes missing in the system, that timestamp is often the only evidence you submitted on time.

How Long CalOptima Has to Decide

California’s Health and Safety Code sets the decision clock. For standard requests, the plan must approve, modify, or deny within five business days of receiving the information it reasonably needs.⁴

Urgent requests get a decision within 72 hours. The ARF has a checkbox for urgent and defines the term narrowly: urgent applies only when the normal timeframe would be detrimental to the patient’s life or health, could jeopardize the ability to regain maximum function, or could result in loss of life, limb, or major bodily function.⁴ Flagging a routine case as urgent won’t speed it up. The plan reclassifies it and processes it on the standard timeline.

Approvals typically post in the provider portal. Denials and modifications come with a written notice explaining the clinical rationale and instructions for appeal.

If the Request Is Denied

A denial is not the end. CalOptima members and providers have several layers of review, and each has its own deadline.

Internal Appeal

Start with CalOptima. Members can file by calling Customer Service at 1-888-587-8088 (TTY 711) Monday through Friday 8 a.m. to 5:30 p.m., submitting the grievance or appeal form online, or mailing a written appeal. CalOptima sends an acknowledgment letter within five calendar days identifying a Resolution Specialist as the point of contact, then has 30 calendar days to resolve the appeal and mail a response. Appeals involving serious health concerns are reviewed within 72 hours.⁵

State Fair Hearing

If the internal appeal doesn’t resolve things, the member can request a State Hearing through the California Department of Social Services. The deadline is 120 calendar days from the date on CalOptima’s Notice of Appeal Resolution. A member can also request a State Hearing if 30 days have passed since filing the appeal and CalOptima has not issued a decision.⁶

Independent Medical Review

For denials based on medical necessity, the California Department of Managed Health Care (DMHC) offers an Independent Medical Review at no cost. The member must first file a complaint or appeal with CalOptima; IMR eligibility opens after disagreeing with the plan’s decision or after 30 days have passed since filing the initial complaint. IMR covers denials, modifications, or delays based on medical necessity, refusals to cover experimental treatment, and refusals to pay for emergency services already received. Medicare enrollees, Medi-Cal fee-for-service members not in a managed care plan, self-insured plan members, and workers’ compensation disputes are not eligible for IMR.⁷

Common Reasons Requests Get Kicked Back

Most delays come from preventable paperwork problems rather than clinical disagreements. The patterns repeat:

Mismatched identifiers. A wrong CIN, NPI, or TIN triggers automatic rejection before a reviewer sees the clinical information.
Missing quantity. The ARF requires a quantity for every procedure code.
Thin documentation. Submitting without supporting records forces the reviewer to request more, which restarts the decision clock.
Wrong fax line. A routine request on the urgent fax, or a pharmacy request on the medical fax, lands with the wrong team.
Wrong form version. A Medi-Cal ARF for a OneCare member, or a medical ARF for a prescription drug, flags immediately as a mismatch.

One last point worth knowing: authorization approval does not guarantee payment. The ARF itself warns that eligibility must be verified at the time services are rendered. If a member loses coverage between the authorization and the service date, the claim won’t be payable even with an approved authorization on file.³

1
CalOptima Health. Prior Authorizations
2
MedImpact. CalOptima Prior Authorization Form
3
CalOptima Health. Authorization Request Form (ARF)
4
California Legislative Information. California Health and Safety Code 1367.01
5
CalOptima Health. Your Rights
6
California Department of Social Services. State Hearing Requests
7
Department of Managed Health Care. Frequently Asked Questions