Treatment Authorization

Overview

Certain medical procedures require prior authorization to ensure medical necessity and appropriateness of care. Utilization Management review is performed for medical necessity determination prior to a non-emergency/elective admission or other course of treatment that requires authorization for payment. 

Procedures Requiring a TAR

Before rendering a service, it is advised that you determine if a TAR is required for the procedure.  Please utilize the HCPCS/CPT Procedure Code - Prior Authorization Requirement Search Tool to see if a TAR is required before the procedure is rendered and reimbursement can be made. Click here to watch a quick video tutorial on how to enter a procedure code and confirm if a TAR is required; in turn this can help avoid a claim denial. Once you have verified if a TAR is required for your procedure, you can submit your authorization request on the provider portal.

Authorization for Medical Treatment & PADs

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

 

20-1 Long Term Care Authorization

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.

 

18-1 Inpatient Treatment Authorization

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 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 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


Time Frames for Utilization Review

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.

TAR Status

  • 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.

TAR Appeal Process

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

Submitting Medical Justification

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

Do you need more information?

Please download our Provider Manual.


Contact Us

  • For clinical questions relating to authorizations, contact the Health Services department at (805) 562-1082
  • For in office authorization training, contact the Provider Services Relations Team at psrgroup@cencalhealth.org