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.

Running an Authorization report

By running the Authorization Report from our Provider Portal, you can see what authorizations have been received and of those, which ones have been approved or denied. Verifying authorizations prior to submitting your claims will assist in delayed payments or claim denials. This tutorial will show you how to run an authorization report for your member and will provide you with the authorization number needed to submit with your claim. Click here to view this tutorial.

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 (RAF) and can be accessed by members directly, click on these links to learn more about RAFs, or view our Frequently Asked Questions document.

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 

Non-Emergency Medical Transportation (NEMT)

CenCal Health members may access Non-Emergency Medical Transportation services when the member does not require emergency services or equipment during transport, but their medical and physical condition precludes the usage of public transportation or driving. Ventura Transit System (VTS) is CenCal Health’s transportation vendor. To schedule transportation services, contact VTS directly at (855) 659-4600.

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.
  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:
    • Members who suffer from severe mental confusion.
    • Members with paraplegia.
    • Dialysis recipients.
    • 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

     a. All NEMT services will require a Physician Certification Statement (“PCS”) Form.

    1. The Physician Certification Form (required for NEMT services) must be initiated by Ventura Transit System (VTS), and then forwarded to the member’s Referring Physician by CenCal Health’s Health Services Department for final signatures.
    2. The provider must complete the remaining items to be filled out on the PCS form. After completion, please fax the form to CenCal Health’s Health Services department at (805) 681-3071 in order to schedule a Non-Emergency Medical Transportation (NEMT).
    3. CenCal Health will notify VTS of the completed form and VTS will schedule and coordinate the member transportation.

     b. Existing prescriptions for NEMT will be honored by CenCal/VTS and reviewed upon their expiration date.
     c. NMT services do NOT require an authorization, and providers are NOT expected to complete a PCS Form for NMT.  


Members and/or Providers may contact Ventura Transit System (VTS) directly at (855) 659-4600 for transportation services or please call CenCal Health’s Member Services Department at 1 (877) 814-1861 for assistance.


 

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