Claims and Eligibility

Post-Stabilization

Non-Contracted Hospital Admission Process – Post-Stabilization

I. Prior Authorization Is Required for Inpatient Post-Stabilization Services

CalOptima Health requires both contracted and noncontracted hospitals to obtain prior authorization before admission for medically necessary inpatient post-stabilization services. Prior authorization is not required for emergency services. For the OneCare Connect (OCC) Cal MediConnect Program (Medicare-Medicaid Plan), observation status does not require an authorization. However, if the treating physician is planning to admit an OCC member under observation to inpatient, a prior authorization is required before the inpatient admission.

II. Requesting Prior Authorization for Inpatient Post-Stabilization Services from CalOptima Health

For Medi-Cal or OCC members enrolled in CalOptima Health Community Network or CalOptima Health Direct-Administrative (collectively, CalOptima Health Direct), both contracted and noncontracted hospitals must request prior authorization before admission for medically necessary inpatient post-stabilization services from CalOptima Health. CalOptima Health requires the treating physician to provide a diagnosis and sufficient information reasonably necessary to make a decision to authorize medically necessary inpatient post-stabilization services.

The following two steps are required to request prior authorization:

1. Call the Utilization Management (UM) Department to obtain a tracking number:

  • 714-246-8686 (Option 2 for Inpatient) – Monday through Friday from 8am to 5pm, Pacific Standard Time (PST);
  • 714-403-1732 – Monday through Friday from 5:01pm to 7:59am PST and all day Saturday, Sunday, and holidays.

2. Once you have obtained the tracking number, fax the clinical information necessary to support your request to a nurse case manager using the fax number that was provided to you along with the tracking number. Please include your contact information (name, phone number, and fax number).

Contact Us
  • Providers and other health care professionals with questions regarding Medi-Cal, OneCare Connect, OneCare or PACE can call the Provider Relations department at 714-246-8600 or email: providerservices@caloptima.org

Electronic Data Interchange (EDI)
Provider Disputes
  • Dispute Process
    Review the payment dispute process for Medi-Cal and OneCare contracted providers

Prior Authorizations

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