Authorizations

authorizeCenCal Health cares about the members we serve and believes in processing authorizations in a timely manner. It is important for providers to understand the difference between referrals, treatment authorization requests and other types of authorizations that may be required and how to obtain each one.

To better assist our providers we have created a Quick Reference Guide for our Authorizations.

Referral Authorization Form (RAF)

A referral is the process of a Primary Care Provider (PCP) sending a member to another provider, like a specialist, for consultation or services that are not be provided by the PCP.

Some services do not require a Referral Authorization Form and can be accessed by members directly. See "When RAFs are Not Required" in the next accordion below, for this list.

Treatment Authorization Request (TAR)

Certain medical procedures require prior authorization to ensure medical necessity and appropriateness of care. CenCal Health makes a list of Procedures Requiring a TAR available to providers.

Learn more about TARs

Documentation of Medical Necessity for Intravenous Sedation & General Anesthesia for Dental Procedures Referral Slip

Second Opinion

CenCal Health members may request a second medical opinion regarding a recommended procedure or service through their PCP. The plan must review the request for medical necessity. 

Self-Referral Services

Certain Medi-Cal covered services do not require prior authorization, irrespective of whether the member seeking the service is enrolled in CenCal Health. 

  • Family planning, sexually transmitted diseases, abortion and HIV testing
  • Acupuncture, chiropractic, audiology, physical therapy (Rx may be required)
  • Emergency services

To obtain more information about services not requiring prior authorization, please call Provider Services at (805) 562-1676.

Pharmacy Authorizations

Prior authorization for pharmacy services not listed on the CenCal Health formulary is required by the ordering provider.

Radiology Authorizations

Prior authorization for high-tech imaging services is required to be completed by the ordering provider.

Services requiring radiology authorization include:

  • CT and CTA
  • PET and PET/CT
  • MRI
  • MRA 
  • Nuclear Cardiology

Learn more about our Radiology Benefit Manager 

List of Services or Referrals

Below is a list of services or referrals that require prior authorization. Obtaining pre-service approval before rendering the services will expedite timely claims payment and prevent the need for CenCal Health to perform a post-service (retrospective) review.

Example of services that require prior authorization include but are not limited to:

  • Scheduled (elective) surgery
  • Non-emergent medical transportation (NEMT)
  • Non-emergent inpatient admissions, including Acute Rehab, SNF, CLHF, Subacute, LTAC
  • Hearing aid(s)
  • DME over $100 or cumulative cost for repairs are over $250
  • Orthotics over $250
    • Therapeutic diabetic shoes and inserts always require prior authorization
  • Prosthetics over $500
  • Home Health services beyond evaluation visit (nursing, PT, OT, Speech, etc.)
  • Home Infusion therapy
  • Genetic testing
  • Services with unlisted/miscellaneous procedure codes
  • Wound care and medical supplies
  • Skilled Nursing Facility, Congregate Living Health Facility, Subacute care setting
  • Non-participating, non-contracted, and out-of-network providers, including tertiary care facilities
  • Radiology and Imaging Services, such as CT, CTA, MRI, MRA, PET, PET/CT, Nuclear Med
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