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 

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