Claims and Eligibility
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.
Authorization Request Form (ARF) Submit along with clinical documentation to request a review to authorize member’s treatment plan.
Authorization Request Form (ARF) OneCare Submit along with clinical documentation to request a review to authorize CalOptima Care Network, OneCare member’s treatment plan.
Speech Therapy, Occupational Therapy and Physical Therapy Authorization Request Tips for Providers
Wheelchair and hearing aid repairs:
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.
2023년 1월~3월 사전 승인이 필요한 시술 코드, 2023년 1월 1일~3월 31일사이 유효.
April-June 2023 (Medi-Cal) View the current prior authorization procedure codes.
April-June 2023 (OneCare) View the current prior authorization procedure codes.
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 January 1, 2022–March 31, 2022
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 information on LTC and CBAS services, please see Long-Term Services and Supports.
Emergency services Urgent care visits Sensitive services (which include family planning) Sexually transmitted disease services AbortionMinor consent services
Human immunodeficiency virus (HIV) testingBasic prenatal care servicesRoutine obstetrics servicesPediatric preventive servicesPrimary and preventive care services
No prior authorization is required for:
All initial requests for specialty consults require a prior authorization from:
The initial prior authorization will include:
Urgent referrals are only to be submitted if the normal time frame for authorization will:
All referrals not meeting urgent criteria will be downgraded to a routine referral request and follow routine turn-around times.
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