How to Fill Out and Submit the CenterLight Prior Authorization Form

CenterLight’s prior authorization form is a one-page fax cover sheet that providers send to the Clinical Review Department at 718-873-2890 before delivering certain inpatient, outpatient, pharmacy, personal care, or durable medical equipment services to a PACE or Managed Long-Term Care member. The CenterLight prior authorization form collects patient identifiers, provider details, diagnosis codes, and the requested service, and it travels with the clinical documentation CenterLight needs to evaluate medical necessity.¹ Standard requests are decided within 14 calendar days; urgent requests are decided within 72 hours.²

Where to Download the Form

The PDF lives at centerlighthealthcare.org/priorauthorization, and the For Providers page links to it under “Provider Resources.”³ You can type into the PDF fields before printing, or print it blank and complete it by hand. Either way, the finished form has to be faxed. CenterLight’s provider portal lets you look up status, but it does not accept new authorization submissions.²

Which Services Need Prior Authorization

CenterLight requires prior authorization for a designated range of inpatient and outpatient procedures across hospitals, ambulatory care facilities, physician offices, and other healthcare settings, as well as for personal care worker services and durable medical equipment.² The provider manual does not publish an exhaustive code list, and the requirements change periodically. Before you schedule, confirm whether a specific code needs authorization by checking the provider portal or calling Clinical Review at 1-833-252-2737 (TTY 711), Monday through Friday, 8 a.m. to 8 p.m.⁴

Delivering a service that required authorization without obtaining it first can result in the claim and payment being denied outright.²

How to Fill Out the Form

The form fits on one page and has three working sections. Walk through them in order.

Request and Patient Information

Enter the submission date and the tentative date of service. Add the patient’s full name and CenterLight Member ID. Indicate who is sending the request: primary care physician, specialist, DME supplier, or pharmacy. Include your phone, fax, and email so Clinical Review can reach you with questions or the decision.¹

Provider and Facility Identifiers

List the referring provider and indicate whether you are referring to yourself. Enter the specialty, then the rendering provider or facility name with phone and fax. The form requires the rendering provider’s NPI number, Tax ID, Medicare provider number, and Medicaid ID. If the service takes place at a facility, add the facility’s Tax ID. Mark the place of service as in-network, out-of-network, or unknown, and write in the full address.¹

Diagnosis and Service Codes

List the ICD-10 diagnosis codes that support medical necessity. Check the box for the type of service: inpatient elective admission, outpatient facility, home, ambulatory surgical procedure, office visit, or inpatient (other). Write a brief description of the service and enter up to eight CPT or HCPCS codes with units.¹ Make sure each service code is clinically consistent with the diagnosis. Mismatched codes are a common trigger for denial.

What Clinical Documentation to Attach

The form is a cover sheet. CenterLight will not process the request without sufficient clinical documentation supporting medical necessity, and the form warns in bold that missing documentation can itself cause a denial.¹ CenterLight bases coverage determinations on Medicare coverage guidelines, nationally recognized evidence-based guidelines, or its own clinical coverage policies, so attach records that speak directly to eligibility and medical necessity under those standards.²

A strong package usually includes:

Recent physician progress notes describing the patient’s current condition and why the service is appropriate.
Relevant lab, radiology, and diagnostic reports.
Specialist evaluations and recommendations, if another provider ordered or endorsed the service.
The current plan of care showing how the request fits into overall treatment.
A hospital discharge summary and related orders when the service follows an inpatient stay.

Depending on the situation, CenterLight may also look for medication administration records, advance directives, and documented contact with caregivers or legal guardians.⁵

How to Submit It

Fax the completed form and all supporting documentation to the Clinical Review Department at 718-873-2890.¹ Every page of the clinical support needs to go through with the cover sheet. An incomplete submission will not be processed, and the review clock does not start until CenterLight has what it needs.

For personal care worker and DME requests, you can also email homeservicerequests@centerlight.org. General clinical review questions go to clinicalreview@centerlight.org.⁴ By phone, call 1-833-252-2737 (TTY 711), Monday through Friday, 8 a.m. to 8 p.m.

Pharmacy-related requests use the same form (mark “Pharmacy” as the sender), but the clinical criteria for non-formulary and specialty drugs are published separately in the Prior Authorization Criteria document on the Formulary Resources page. Check that page for the current version before submitting a drug request.⁶

Save the fax confirmation page. That timestamp is your proof of submission if a dispute later arises over when CenterLight received the request.

Timelines and How to Check Status

Standard decisions are issued within 14 calendar days of receipt of a complete submission. Expedited decisions, used when delay could seriously harm the patient’s life or health, are issued within 72 hours.² The 14-day period can be extended by up to another 14 days under certain circumstances.⁷

If CenterLight needs more information, the plan will contact you by phone, fax, email, or written notice and specify what is missing. Not responding can lead to denial. Decisions on standard requests are faxed to providers; if the fax fails or none was provided, notification comes by phone. Any adverse determination arrives in writing with the reason and appeal instructions. Approvals carry a unique authorization number that must appear on all claims for the service.²

To track a pending request, log into the provider portal at centerlight.ppi.com/provider/sign_in, which shows authorization status, claims data, and member eligibility in real time. First-time users can register by calling 1-800-761-5602.⁸

If the Request Is Denied

The written denial notice states the reason and your appeal options. Providers can dispute a payment decision, including medical necessity and administrative denials, by submitting a written appeal within 90 days of the explanation of payment. Include the claim ID number, date of service, authorization number, participant ID, provider ID and NPI, and the reason for the dispute.² Submit it one of three ways:

Email: claimsappeals@centerlight.org
Fax: 718-888-5972
Mail: CenterLight Healthcare, 136-65 37th Avenue, Flushing, NY 11354

CenterLight responds within 60 days of receiving the written appeal and supporting documentation. An unfavorable outcome comes as a Letter of Determination, after which you can file a second-level appeal with additional documentation or initiate arbitration under your provider agreement.²

When the denial is based on medical necessity, the member or, for concurrent and retrospective denials, the provider can file an external appeal with the New York Department of Financial Services for independent review. Members have four months from the final adverse determination (or from waiver of the internal appeal) to file. Providers appealing on their own behalf have 60 days. Missing those deadlines ends the right to external appeal.⁹

1
CenterLight Healthcare. CenterLight PACE Prior Authorization Request Form
2
CenterLight Healthcare. CenterLight Healthcare Provider Manual
3
CenterLight Healthcare. For Providers
4
CenterLight Healthcare. CenterLight PACE Provider Quick Reference Guide
5
CenterLight Healthcare. For Providers: Strengthening Care Through Collaboration
6
CenterLight Healthcare. Formulary Resources
7
New York State Department of Health. New York State Medicaid Managed Care Service Authorization and Appeals Timeframe Comparison
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PPi Provider Portal. Welcome to CenterLight Health System – Sign In
9
Department of Financial Services. New York State External Appeal