Referral Authorization Process

Learn more about RAFs

RAFs allow Primary Care Providers (PCPs) to refer their assigned members to a specialist for services outside of the PCPs practice scope. For more information see the CenCal Health Provider Manual.

Is a RAF required?

Referral Authorization Form (RAF) is required for all case managed CenCal Health members; however, there are a number of exceptions to this rule.  Please reference the list below for self referral services that do not require a referral or our RAF Exceptions list.  

Self-Referral Services

  • Family planning, sexually transmitted diseases, abortion and HIV testing
  • Acupuncture, chiropractic, audiology, physical
  • Therapy (Rx may be required)
  • Emergency services
  • First month of eligibility assigned to CenCal Health as Special Class and/or Members residing in a Long Term Care facility
  • Mental Health Psychotherapy
  • Mental Health Medication Management Services

Referrals to Out of Area Providers

Out of area or non-contracted providers require an approved authorization when seeing CenCal Health members.  Please utilize our Utilization Management Authorization Download Form to refer. Authorization ‘A’ number (#) will be generated and faxed to the point of contact listed on the form once a determination is made

All contracted providers have access to our Provider Portal Restricted site to submit electronic RAFs.

Form Requirements:

  • Member Name, ID#, DOB, Age
  • Diagnosis Code & ICD-10 Code
  • Referring Provider Group NPI#
  • Provider Rendering Service MD NPI# & Group NPI#
  • Office Contact
  • List all Procedures Requested with CPT or HCPCS, Qty, Units

Submit Via:

Fax Adult (21yrs and older) documentation

    (805) 681-3071

Fax Pediatric (0-20yrs) documentation

    (805) 692-5140

 

Secure Link https://gateway.cencalhealth.org/form/hs


Authorization Review Timeframe

CenCal has the responsibility to review authorizations in a timely manner. The timeframes indicated below allow for the utilization management team to properly evaluate and determine for appropriateness of medical care services.

  • Emergency Care: No prior authorization required.
  • Routine authorizations: 5 working days with appropriate documentation. If further documentation is required allow up to 14 days.
  • Expedited authorizations: 3 working days. CenCal Health may extend the 3 working days’ time period by up to 14 calendar days if there is a need for additional information.
  • Retroactive authorizations: Review determinations will occur within 30 days of receipt of the request for coverage.

RAF Submission & Status

Contracted Primary Care Physicians (PCP) Groups have access to submit referral requests to outpatient specialists via the Provider Portal.  Please watch our Portal training videos when submitting these requests, in addition to our authorization 'Status' code results.

 

Status Results:

  • Approved
    • The RAF has been approved for the specified date span.
    • The majority of RAFs will be processed and approved within 24 hours of receipt.
  • Pending/Sent for Review
    • The RAF requires manual review.
    • Provider Portal authorization requests can be updated by adding additional remarks and downloading additional documents (all other fields are locked).
    • Please resubmit your authorization request if the locked fields (Servicing Providers, Diagnoses Code entry, etc.) needs revisions
  • Denied
    • The returned RAF states specifically why the decision was made and a description of the appeal process will be attached.

Below are examples of why a RAF may Pend for Review.

  • Referral to provider outside of Santa Barbara or San Luis Obispo County, see Referrals to Out of Area Providers section
Member is under the age of 21 is referred to one of the following providers:
  • Cardiology
  • Endocrinology
  • Gastroenterology
  • General Surgery
  • Neurological Surgery
  • Neurology
  • Nephrology
  • Oncology/Hematology
  • Ophthalmic Plastic Surgery
  • Orthopedic Surgery
  • Pediatric Cardiology
  • Pediatric Neurology
  • Pediatric Nephrology
  • Pediatric Surgery
  • Pediatric Urology
  • Pediatric Gastroenterology
  • Rheumatology
  • Urology

RAF Appeal Process

If a provider receives a denial, deferral or modification of RAF , the provider may contact the physician reviewer or file an appeal by calling or writing to the address and/or phone number below.

CenCal Health
Medical Management Department
4050 Calle Real
Santa Barbara, CA 93110
(805) 562-1082

Be sure to include these items in your documentation:

  • A copy of the original submitted RAF and denial notification
  • A letter stating why denial or modification should be overturned
  • Documentation to support overturning the original denial or modification

Special Interest to PCPs

Below are examples of situations you may encounter when managing your RAFs.

CenCal Health can assist in the following areas when needed:

  • Retrospective RAF Request- a RAF can be obtained by contacting the member’s assigned PCP
  • ER or Hospital Follow up Visits- Issue a one-time consult
  • Member not established- Issue a one-time consult
  • Contact Medical Management if you are unable to obtain a RAF from the PCP at (805) 562-1082