The UCLA Medical Group prior authorization form — formally the UCLA Health Medicare Advantage Prior Authorization Request Form — is the document your provider submits to get pre-approval for a medical service, procedure, or device before it’s performed. Send the completed form to the plan’s Prior Authorization Department by fax at 1-424-234-7893 or by email at HPUM@mednet.ucla.edu. Under the 2026 federal timeline, the plan must issue a standard decision within 7 calendar days, or within 72 hours for urgent requests. Approval depends on medical necessity, covered benefits, and your eligibility at the time the service is rendered.
Where to Get the Current Form
The form is a fillable PDF on the UCLA Health Medicare Advantage resources page at uclahealthmedicareadvantage.org. A provider’s office can also request a hard copy by calling Member Services at 1-833-627-8252 (TTY: 711).1UCLA Health Medicare Advantage. Medicare Advantage Forms and Information Two versions are in circulation: an older one and a version updated in early 2026. Use the most recent form linked on the resources page. Older versions may be rejected or slow down processing.
Request Type and Patient Information
The top of the form asks the provider to classify the request. Checkboxes include New Request, Modify (with a field for the existing authorization number), Second Opinion, and Experimental. Most submissions are new requests.
The provider then selects a priority level:
- Routine, for standard turnaround.
- Retro, for services already performed. These must be submitted within 30 calendar days of the service date.
- Urgent, for time-sensitive clinical situations.2UCLA Health Medicare Advantage. Prior-Authorization and Exception Request Form
An urgent request requires selecting a qualifying reason on the form, such as transplant evaluation, hospital discharge, inpatient hospice, or a situation where the member’s life, health, or ability to regain maximum function is in serious jeopardy.3UCLA Health Medicare Advantage. Prior-Authorization Request Form Checking “Other Urgent” requires a written explanation. Tagging a routine request urgent without clinical justification generally won’t speed it up; the plan is likely to reclassify it and process on the standard timeline.
Next the provider identifies the plan name (Principal or Prestige) and notes any additional insurance coverage, including the other carrier’s name and policy number if applicable. The patient information section requires your full legal name, Member ID, date of birth, phone number, and address. These fields are marked required. A transposed digit in a Member ID or a nickname in place of a legal name is enough to bounce the request back before a clinical reviewer sees it.2UCLA Health Medicare Advantage. Prior-Authorization and Exception Request Form
Requesting and Rendering Provider Details
The form separates two roles. The requesting provider is the physician or office initiating the authorization, usually your primary care provider or a specialist who has determined you need the service. This section captures the provider’s name, type (primary care, specialist, or vendor/ancillary), phone, fax, contact person, and address.
The rendering provider is the physician, facility, or vendor that will actually perform the service. It may be the same person as the requesting provider, or it may be a hospital, imaging center, or surgical group. Required fields include name or facility name, specialty, NPI, phone, contact name, fax, and address. The NPI is the 10-digit identifier assigned to every healthcare provider and is used to verify network status and professional standing.4Centers for Medicare & Medicaid Services. NPI Fact Sheet
If the rendering provider is out-of-network or outside the medical group, there is a field to explain why. That explanation matters. UCLA Health Medicare Advantage is an HMO plan, meaning members generally must use plan providers except for emergency or urgent care.1UCLA Health Medicare Advantage. Medicare Advantage Forms and Information
Diagnosis, Service Codes, and Clinical Justification
This is where most requests succeed or fail. The form requires at least one valid ICD-10 diagnosis code and at least one valid CPT or HCPCS service code. The diagnosis code describes your condition; the service code describes what the provider wants to do about it. If the two don’t line up — a knee pain diagnosis paired with a shoulder MRI, for example — the request gets denied on its face.
The service code table has columns for code, modifiers, quantity, and description. If no quantity is entered, the form defaults to one unit. Quantities have to match valid CPT/HCPCS values; an impossible number of units flags the submission for rejection.2UCLA Health Medicare Advantage. Prior-Authorization and Exception Request Form
Below the codes is a free-text Clinical Justification/Medical Necessity section. Vague statements like “patient needs procedure” accomplish nothing. Effective justifications describe the diagnosis, what treatments have already been tried, why those were insufficient, and how the proposed service is expected to improve the condition. Reviewers compare this narrative against medical necessity guidelines, so specificity carries the request.
The last section covers hospital status (inpatient or outpatient/observation), date of service, and additional comments. The provider signs and dates the form at the bottom.
Records to Attach
Codes and a short narrative rarely stand alone. Supporting medical records give the reviewer the evidence to approve the service. Recent office visit notes should describe your symptoms, the physician’s assessment, and the treatment plan that led to the request.
Objective test results carry real weight: lab work, MRI or CT imaging reports, pathology results, specialist consultation notes. Documentation showing that less intensive treatments were tried and didn’t resolve the problem is especially useful. Insurers follow tiered treatment protocols, and jumping to an expensive procedure without evidence that simpler options failed is one of the most common reasons for denial.
Every page of supporting documentation should include the patient’s name and Member ID. Faxed pages arrive out of order or get separated, and unlabeled records may never get matched to the right request.
Separately, if your provider believes Medicare may deny payment based on medical necessity, they should give you an Advance Beneficiary Notice of Noncoverage (Form CMS-R-131) before performing the service. The ABN transfers potential financial liability to you and lets you decide whether to proceed. As of March 2026, providers must use the updated version approved by the Office of Management and Budget.5Centers for Medicare & Medicaid Services. FFS ABN
How to Submit
UCLA Health Medicare Advantage accepts prior authorization requests two ways:
- Email non-delegated authorization requests to HPUM@mednet.ucla.edu. The plan coordinates the review with you and your provider’s team after receiving it.6UCLA Health Medicare Advantage. Healthlink Medicare Provider Portal
- Fax the completed form and all supporting documentation to the Prior Authorization Department at 1-424-234-7893. Keep the transmission receipt as proof of delivery.7UCLA Health Medicare Advantage. Organization Determination
Network providers already set up on the HealthLink Medicare Provider Portal at healthlink.uclahealthmedicareadvantage.org can use it to check managed care eligibility, submit and review referrals, and track claim status after filing.6UCLA Health Medicare Advantage. Healthlink Medicare Provider Portal
How Long the Decision Takes
Federal timelines tightened in 2026. Under the CMS Interoperability and Prior Authorization Final Rule, Medicare Advantage plans must issue standard prior authorization decisions within 7 calendar days of receiving the request, down from the previous 14 calendar days.8Centers for Medicare & Medicaid Services. CMS Interoperability and Prior Authorization Final Rule CMS-0057-F Expedited decisions for urgent situations must come within 72 hours. Part B drug requests must be answered within 72 hours regardless of whether the request is marked urgent.9eCFR. 42 CFR 422.568 – Standard Timeframes for Organization Determinations
The plan can extend the standard 7-day window by up to 14 additional calendar days in limited situations: if you request the extension, if the plan needs additional medical evidence from a non-contract provider that could change a denial, or if extraordinary circumstances make the extension justified and in your interest.9eCFR. 42 CFR 422.568 – Standard Timeframes for Organization Determinations If the plan takes an extension, it must notify you in writing with the reason and your right to file a grievance.
If Your Request Is Denied
A denial is not the end of the road, and the clock starts on the date of the denial notice. Medicare Advantage enrollees have at least 60 days from that date to file a reconsideration, which is the first level of appeal. The plan then has 30 calendar days to decide a standard reconsideration for services and items, or 72 hours for an expedited reconsideration when your condition requires faster action.10eCFR. 42 CFR 422.590 – Timeframes and Responsibility for Reconsiderations
Before filing a formal appeal, ask your provider to request a peer-to-peer review. This is a phone call between your treating physician and the plan’s medical director where the clinical rationale gets discussed in real time. Not every denial qualifies, but these conversations resolve a fair number of denials that were driven by incomplete documentation rather than genuine disagreement about medical necessity.
If the plan upholds its denial on reconsideration, the case automatically moves to an Independent Review Entity contracted by Medicare. Further appeal levels beyond that, along with their deadlines and procedures, are described in the denial notice.
Emergency and Post-Stabilization Care
Prior authorization is not required for emergency services. If you go to an emergency room, the plan covers stabilizing care regardless of whether the facility is in-network. The authorization question comes up afterward. If you need continued inpatient care before you can safely be discharged or transferred, your provider must submit a separate post-stabilization care authorization request. The plan is required to respond within 30 minutes. If no response comes in that window, the request is considered approved by default, and the plan remains financially responsible for the care.11California Health & Wellness. Learn More About New Post-Stabilization Authorization Requirements
Notifying the plan about an ER visit or inpatient admission does not satisfy the post-stabilization authorization requirement. The request must explicitly state that the patient has been stabilized and include the clinical information and a callback number for the requesting provider.