Providers can submit a Medical 50-1 Authorization via the Provider Portal Restricted site. Follow guidelines below for authorization required for medical procedures, surgeries or DME supplies.
Medical 50-1 Treatment Authorization
Physician- Administered-Drug (PAD) requests are submitted directly to CenCal Health for reimbursement. Requests that are over the codes service limit or outside the diagnosis requirements require a TAR submission
The 20-1 LTC Authorization form is used to determine the medical necessity for admission and for continued stay in a skilled nursing facility, subacute care, a congregate living health facility, and should be submitted only by those facilities. Follow guidelines within the training video below for authorization requirements when submitting via the Provider Portal Restricted Site.
An 18-1 Inpatient Authorization is used to determine the medical necessity for admission and for continued acute care and to facilitate a transfer or transition of care. This should be submitted by the Admitting inpatient hospital, rehab clinic, or Long Term Acute Care (LTAC) facility. Follow guidelines within the video training below for authorization requirements for Members admitted to an inpatient or rehab facility.
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 RAF, TAR, 18-1, 20-1 Authorizations.
Form Requirements:
- Member Name, ID#, DOB, Age, Diagnosis Code & ICD-10 Code
-
RAF or TAR
Referring Provider Group NPI
Provider Rendering Service MD NPI# & Group NPI#
Office Contact
18-1 or 20-1
Indicate Inpatient Faciltiy, Outpatient Facility or SNF
Effective Dates & Through Date
Facility 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
CenCal Health has the responsibility to review authorizations in a timely manner.
The time frames 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.
- Post Service/Retroactive authorizations: Allow up to 30 calendar days of receipt of the request for review.
- Approved
- The TAR has been approved for the specified date span.
- Pending/Sent for Review
- The TAR requires manual review.
- Denied
- The returned TAR states specifically why the decision was made and a description of the appeal process will be attached.
If a provider receives a denial, deferral or modification of a TAR, 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
Providers may appeal a denied or modified TAR by submitting the TAR Appeal Form document within 90 calendar days from the date of the original decision.
Be sure to include these items in your documentation:
- A copy of the original TAR and denial notification
- A letter stating why denial or modification should be overturned
- Documentation to support overturning the original denial or modification
For full review, authorizations need supporting documentation for medical justification. This can be done in three easy ways!
Portal Upload Attachments
Fax Adult (21yrs and older) documentation
(805) 681-3071
Fax Pediatric (0-20yrs) documentation
(805) 692-5140
Secure File Drop
https://gateway.cencalhealth.org/form/hs
Faxing & Secure File Drop Requirements:
- Add a cover page
- Point of Contact Phone/Email Address
- Contact Name
- Department
- Number of pages you are faxing over
- Reference the Auth# on the top of every document