The Imperial Health Plan prior authorization form is a one-page document your provider completes and faxes to the plan to get approval before certain services or procedures are delivered. You download the current version from Imperial Health Plan’s provider resources page, fill in five labeled sections covering member, diagnosis, procedure, and service details, attach clinical records that support medical necessity, and fax it to the standard or urgent line depending on how time-sensitive the request is.
Where to Download the Current Form
Medicare Advantage providers get the form from the main provider page at imperialhealthplan.com, under the “Forms” heading.1Imperial Health Plan. Providers Marketplace (exchange) plan providers use a separate version posted on the Imperial Insurance Companies provider page, which also hosts the current prior authorization list and a pre-certification referral form. The exchange-side form was most recently updated in March 2026.2Imperial Insurance Companies, Inc. Providers
Download a fresh copy each time rather than reusing one saved months ago. Both pages also link to the provider portal, where you can submit requests electronically and track their status in real time instead of faxing.1Imperial Health Plan. Providers
Confirm the Service Needs Authorization
Not every service requires it. Imperial Health Plan publishes a prior authorization list spelling out exactly which services need advance approval, spanning dozens of categories including inpatient hospital admissions, certain cardiology procedures like diagnostic catheterizations and stress echocardiograms, durable medical equipment such as power wheelchairs, cochlear implants, home health care, hysterectomies, cosmetic and reconstructive procedures, behavioral health services, cancer supportive care drugs, continuous glucose monitors, and gender dysphoria treatment.3Imperial Health Plan. Imperial Health Plan Prior Authorization List If the service appears on the list, it needs authorization before it can be ordered or performed, and only services deemed medically necessary are covered.
How to Complete the Five Sections
The form is divided into five labeled sections, and partial submissions slow everything down. The form instructs providers to complete all sections and include clinical records that support medical necessity.4Imperial Health Plan. Imperial Health Plan Prior Authorization Form
Section A: Member Information
Enter the member’s full legal name (last, first, middle), date of birth, and Imperial Health Plan member ID number from their insurance card. Then fill in the primary care physician’s name, NPI number, phone, and fax. If a different doctor is making the referral, that physician’s information goes in the separate “Referring Physician” fields.4Imperial Health Plan. Imperial Health Plan Prior Authorization Form
Section B: ICD-10 Diagnosis Codes
List the ICD-10-CM diagnosis codes describing the patient’s condition along with a written description for each. These codes tell the review team why the requested service is necessary. Use the most specific code available. A vague or overly broad code is one of the fastest ways to trigger a request for more information.
Section C: CPT/HCPCS Procedure Codes
Enter the CPT or HCPCS code for each requested procedure. The form provides space for a primary code and several additional codes, plus columns for description, quantity, and units.4Imperial Health Plan. Imperial Health Plan Prior Authorization Form Double-check that procedure codes match the diagnosis codes. A mismatch between what’s wrong with the patient and what you’re proposing to do about it raises an immediate red flag.
Section D: Referred-To Provider or Facility
Fill in the specialist’s or facility’s name, NPI number, phone, fax, and physical address. You also pick the referral priority here, standard or urgent, using the checkboxes. Include the name and direct number of the person completing the form so the plan can reach someone quickly if questions come up.4Imperial Health Plan. Imperial Health Plan Prior Authorization Form
Section E: Service Information
Check the box that matches where the service will take place: office visit, home, ambulatory surgical center, DME, inpatient/acute, outpatient hospital, rehab/LTAC, or skilled nursing facility. Then enter the requested date of service and, for hospital stays, the scheduled admission date.4Imperial Health Plan. Imperial Health Plan Prior Authorization Form
Standard or Urgent: Which to Pick
The urgency designation in Section D controls both the fax number you use and how fast the plan must respond. CMS defines an expedited (urgent) request as one where waiting under the standard timeframe could seriously jeopardize the member’s life, health, or ability to regain maximum function.4Imperial Health Plan. Imperial Health Plan Prior Authorization Form If the situation doesn’t meet that threshold, the plan will downgrade it to a routine request and process it on the standard timeline. Marking something urgent when it isn’t won’t speed anything up; it adds a reclassification step.
Where to Fax the Form
Imperial Health Plan uses separate fax lines for standard and urgent requests. Do not combine requests for different specialties in a single fax transmission.4Imperial Health Plan. Imperial Health Plan Prior Authorization Form
- Standard requests: fax to (626) 283-5021 or toll-free (888) 910-4412.
- Urgent requests: fax to (866) 811-0455.
- Status checks: call (626) 838-5100, Option 1.
Attach all supporting clinical records with the form: progress notes, lab results, imaging reports, or anything else that demonstrates medical necessity. The review team bases its decision on what you send, and thin documentation is the most common reason requests stall or get denied.
What Happens After You Submit
Standard prior authorization requests for medical items and services require a decision within seven calendar days as of January 1, 2026, down from the previous fourteen-day window. Expedited requests still require a decision within 72 hours.5Centers for Medicare & Medicaid Services. Moving Prior Authorization Into the 21st Century These are outer limits, not targets, and many straightforward requests resolve in a day or two.
Once a decision is reached, Imperial Health Plan sends a written notice to both the requesting provider and the member. An approval notice includes an authorization number you’ll need on all related claims. Keep that number somewhere accessible; submitting claims without it is a reliable way to get them kicked back. An authorization is not a guarantee of payment. If a member’s coverage lapses between the approval date and the service date, the claim can still be denied.4Imperial Health Plan. Imperial Health Plan Prior Authorization Form
If the Request Is Denied
A denial comes as a formal written notice called an Integrated Denial Notice, which CMS requires Medicare Advantage plans to issue whenever they deny, reduce, or discontinue a requested service.6Centers for Medicare & Medicaid Services. MA Denial Notice The notice explains the clinical reasoning and lays out the member’s appeal rights.7Imperial Insurance Companies. Preauthorization Requirements and Process
Many providers start with a peer-to-peer review, a phone call between the treating physician and the plan’s medical director to explain clinical nuances that documentation alone might not convey. These requests are time-sensitive; for Medicare Advantage plans, providers generally have only a few calendar days from the denial to request one. Only the treating or ordering physician, or a covering physician, nurse practitioner, or physician assistant, can participate.
If the denial stands, the member or provider can file a reconsideration request within 60 calendar days of receiving the written denial notice. The reconsideration must be reviewed by someone not involved in the original decision, and if the issue is medical necessity, the reviewer must be a physician with relevant expertise.8eCFR. 42 CFR Part 422 Subpart M – Grievances, Organization Determinations, and Appeals A denied reconsideration moves automatically to an independent review organization without any further action by the member or provider.
A Note on New Members in Active Treatment
If a member joined Imperial Health Plan while already in the middle of an active course of treatment, federal rules provide a 90-day transition period during which the plan cannot require prior authorization for treatment that was already underway before enrollment.9Martin’s Point Health Care. Continuity of Care: CMS 90-Day Rule Reminder You don’t need to file the form for care that falls inside that window. Once the 90 days end, the plan can reassess medical necessity and start requiring authorization going forward.