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.

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.

Inpatient

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.

Outpatient

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.

2023年一月至三月需要預先授權治療的清單，生效日 01/01/2023 至 03/31/2023。

April-June 2023 (Medi-Cal) View the current prior authorization procedure codes.

April-June 2023 (OneCare) View the current prior authorization procedure codes.

Past authorization required complete procedure codes 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 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 information on LTC and CBAS services, please see Long-Term Services and Supports.

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
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.

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)

Eligibility/Benefit Inquiry and Response (270/271)
When to use eligibility and benefit inquiry and response
Claim Status Inquiry and Response (276/277)
When to use claim status inquiry and response

Provider Disputes

Dispute Process
Review the payment dispute process for Medi-Cal and OneCare contracted providers

Prior Authorizations

Authorization required procedure codes
The authorization required procedure codes list for medical and outpatient services should be used for services rendered.

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