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

Non-Emergency Medical Transportation (NEMT)

NEMT is a covered service when a the member’s medical and physical condition is such that transport by ordinary means of public or private conveyance is contraindicated and transportation is require for obtaining medically necessary covered services.  This scheduled transportation is covered when prescribed by in writing by a physician, dentist, podiatrist, or mental health or substance use disorder provider.

Non-Emergency Medical Transportation (NEMT) & Non-Medical Transportation (NMT) Services Reference Guide

Types of NEMT Transportation

AMBULANCE service may be used for:

  1. Transfers from an acute care facility to another acute care facility
  2. Transport for members who have recently been placed on oxygen (does not apply to members with chronic emphysema who carry their own oxygen for continuous use).
  3. Transport for members with chronic conditions who require oxygen if monitoring is required.
  4. Transfers between facilities for members who require continuous intravenous medication, medical monitoring or observation.

LITTER VAN service may be used when the member’s medical and physical condition does not meet the need for NEMT ambulance services, but meets both of the following:

  1. Requires that the member be transported in a prone or supine position, because the member is incapable of sitting for the period of time needed to transport.
  2. Requires specialized safety equipment over and above that normally available in passenger cars, taxicabs or other forms of public conveyance

WHEELCHAIR VAN service may be used when the member’s medical and physical condition does not meet the need for litter van services, but meets any of the following:

  1. Renders the member incapable of sitting in a private vehicle, taxi or other form of public transportation for the period of time needed to transport [
  2. Requires that the member be transported in a wheelchair or assisted to and from a residence, vehicle and place of treatment because of a disabling physical or mental limitation (22CCR Section 51323 (3)(B)).
  3. Requires specialized safety equipment over and above that normally available in passenger cars, taxicabs or other forms of public conveyance
  4. Members with the following conditions may qualify for wheelchair van transport when their providers submit a signed Physician Certification Statement (PCS) form

1)     Members who suffer from severe mental confusion

2)     Members with paraplegia

3)     Dialysis recipients

4)     Members with chronic conditions who require oxygen but do not require monitoring.

AIR Transport for NEMT will be provided only when transportation by air is necessary because of the member’s medical condition or because practical considerations render ground transportation not feasible.  The necessity for transportation by air shall be substantiated in a written order of a physician, dentist, podiatrist, or mental health or substance use disorder provider.

Authorization Requirements

All NEMT services will require an authorization from CenCal Health

NEMT Authorization approval must be initiated through a Physician Certification Statement (“PCS”) Form, completed by the member’s Referring Physician

Existing prescriptions for NEMT will be honored by CenCal/VTS and reviewed upon their expiration date

NMT services do NOT require an authorization, and providers are NOT expected to complete a PCS Form for NMT  



 

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