Prior Authorizations
Authorization required procedure codes
All elective services at Tertiary Level of Care centers require prior authorization. Requests must include justification for tertiary level of care. Tertiary Level of Care is specialized care that is requested by a member’s primary care provider (PCP) or specialist physician.
- Scheduled inpatient admissions require prior authorization.
- All emergency admissions require notification within 24 hours.
- All post stabilization services require authorization by the Utilization Management department.
Speech Therapy, Occupational Therapy and Physical Therapy Authorization Request Tips for Providers
Wheelchair and hearing aid repairs:
- CalOptima Health does not require prior authorization for wheelchair or hearing aid repairs less than $250.
- Covered benefit and frequency limitations will apply.
Current authorization required complete procedure codes list
This is only a list of prior authorization procedure codes. It is not a complete description of benefits. For more information contact CalOptima Health or read the Member Handbook.
Past authorization required complete procedure codes list
Effective July-September 2023 (Physician-Administered Drug Prior Authorization Required List)
Effective July-September 2023 (Medi-Cal)
Effective July-September 2023 (OneCare)
Effective April - June 2023 (Medi-Cal)
Effective April - June 2023 (OneCare)
Effective April-June 2023 Physician-Administered Drug Prior Authorization Required List
Effective February 1, 2023 - March 31, 2023 (Medi-Cal)
Effective February 1, 2023 - March 31, 2023 (OneCare)
Effective January 1, 2023 - January 31, 2023
Effective October 1, 2022 - December 31, 2022
Effective July 1, 2022 - September 30, 2022
Effective April 1, 2022–June 30, 2022
Effective January 1, 2022–March 31, 2022
Important Information for Providers
Effective January 1, 2023, OneCare Medi-Cal “wrap services” will be reviewed by CalOptima Health for all health networks.
These services include, but are not limited to: incontinence supplies, hearing aids and evaluations, Long-Term Care (LTC), and Community-Based Adult Services (CBAS). Please see the Medi-Cal Wrap Services Authorization List and instructions on how to submit your request to CalOptima Health via the Provider Portal.
For CalOptima Health Community Network
- CalOptima Health Direct (COD) Administrative members without an assigned primary care provider do not require authorization for initial consult visits
- Prior authorization is not required for UCI Medical Center specialty follow-up visits for CalOptima Health Community Network (CCN) members, except for extended visits (99215)
- Non-contracted providers: All services provided by non-contracted providers require prior authorization, regardless of whether the codes are listed on the CalOptima Health Prior Authorization Required List
- Codes not on the CalOptima Health Prior Authorization List are subject to Medi-Cal benefit and quantity limitations. Please check the Medi-Cal website for these determinations
- Behavioral health codes for Medi-Cal and OneCare members are included on this list
- All “By Report” codes require prior authorization
- No prior authorization is required for:
Emergency services
Urgent care visits
Sensitive services (which include family planning)
Sexually transmitted disease services
Abortion
Minor consent services
Human immunodeficiency virus (HIV) testing
Basic prenatal care services
Routine obstetrics services
Pediatric preventive services
Primary and preventive care services
CalOptima Health Community Network Prior Authorization
Primary Care (PCP)
No prior authorization is required for:
- Assigned PCP; or
- Affiliated group physician
Specialty Care (SCP)
All initial requests for specialty consults require a prior authorization from:
- Assigned PCP; or
- Contracted SCP
The initial prior authorization will include:
- One specialty consult; plus
- As many routine follow-ups as necessary (excluding office code 99215, which requires a new prior authorization)
Urgent Referrals (PCP and SCP)
Urgent referrals are only to be submitted if the normal time frame for authorization will:
- Be detrimental to the patient's life or health; or
- Jeopardize patient's ability to regain maximum function; or
- Result in loss of life, limb or other major bodily function
All referrals not meeting urgent criteria will be downgraded to a routine referral request and follow routine turn-around times.
Contact Us
- Providers and other health care professionals with questions regarding Medi-Cal, OneCare Connect, OneCare or PACE can call the Provider Resource Line 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
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