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

Some procedures do not require a TAR. Click the following link to look up your procedure code in an interactive form.

Authorization for Medical Treatment

Follow guidelines below for authorization required for medical procedures, surgeries or DME supplies.

For Medical Treatment Authorization use the 50-1 TAR form
Fax completed 50-1 TAR with supporting medical documentation to (805) 681-3071

Authorization for Long Term Care

Follow guidelines below for authorization required for Long Term Care (LTC), Skilled Nursing Facilities (SNF) or Intermediate Care Facility (ICF).

Authorization for Inpatient Treatment

Follow guidelines below for authorization required for Members admitted to an inpatient or rehab facility.

For additional information please reference the provider manual.

Out of Area Providers

Out of Area, non-contracted providers must submit prior authorization using a Paper TAR.

To order paper TARs, contact State Medi-Cal at (888) 541-5555


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.
  • Retroactive authorizations: 5 working days with appropriate documentation. If further documentation is required allow up to 14 days Review determinations must occur within 30 calendar days of receipt of the request for coverage.

TAR Submission Process

Follow these to submit a TAR:  

  1. Verify member eligibility 
  2. Does the member have other health coverage?
    • The Other Health Coverage (OHC) always acts as the primary. Once an EOP or a denial has been received, a TAR may then be submitted to CenCal Health
  3. Verify that a TAR is required
  4. Click here to submit eTAR
  5. Fax supporting documentation to (805) 681-3071

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
Health Services Department
4050 Calle Real
Santa Barbara, CA 93110
(805) 562-1820

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

Do you need more information?

Please download our Provider Manual.

providercontactContact 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 department at (805) 562-1676