Utilization Management

 

 

Where I How to Submit Authorizations:

All referrals must be submit by the member ‘s PCP.

 

PCP can fax request on the IPAs referral form with supporting documentation to the UM Dept at (562) 888-9096 Paper TARs Submission:

Electronic submission:

PCP can login to easycaremso.com

 

Referral Turn around time

 

Direct Access:

  • PCP can fill out Direct Access form and provide to member to schedule an appointment with specialist or submit the direct access request through the web System can auto approve ifrequested service meet the direct access guidelines.

Standard/Routine Request:

  • Medi-Cal – 5 business days
  • CaIMedi-Connect – 5 business days
  • CCA – 5 business days

o    Medicare: 14 Calendar days

Urgent/Expedited Request :

 

o    All LOB (Medi-Cal, Medicare, CCA) – 72 hours

 

NOTIFICATION OF APPROVAL/ DENIAL /MODIFICATION/DELAY

Denials, modify of authorization due to coverage determination and medical necessity determinations are based medical criteria. Provider and member can request for copy of criteria use to make determination.

Approval:

o    Approval letter faxed to PCP & Specialist within 24 hours from approval date

o   Approval letter mail to member within 24 hours from approval date.

Delay/Pended:

  • Health Plan Tracking# – Certain services require tracking #’s from the Health Plan, case are being pended until we get tracking
  • Pending Letter of Agreement (LOA) – IPA waiting for LOA to be sign by the specialist/facilit

 

  • Pending for additional information – When the IPA’s Medical Director require additional information to make decision. While requesting for these record a pended/delay letter is issue to the member and mail within 24 hours, letter also faxed to PCP or specialist via fax . . Information must be provided to the IPA within the following time frames in order to make final decision.
  • Medi-cal- 14 days
  • Molina -14 days (any line of business)
  • Commercial-45 days from defer ral date
  • Medicare (Senior) – DO NOT DEFER – 14 days

 

Denial/Modification:

 

o    Denial letter faxed to PCP & Specialist within 24 hours from approval date

o  Denial Letter mail to member within 24 hours from approval date.

 

CARVED OUT SERVICES – Services that are not provided by the IPAs

 

Mental Health: Behavioral referral. Some LOB require coordination with health plan. (See DOFR)

o    Easy Choice Health Plan – process by IPA.

Optometry: Vision care for some health plans are carved out except

 

  • Care 1st Medi-cal – Eye exam only for adult over age 21 y/ Eye exam and Glasses for member under age 21 process by the IPA.
  • Central Health Plan – Eye exam only (Provider get approval from CHMP for Glasses)
  • Regional Center: Developmental delay conditions for evaluation and possible therapy for member ages 0 -3 year of age. Provider to coordinate with Regional Center.

Early Start Program – Speech, PT and OT for pediatric patient 3-5 years old. School District – Speech, PT, OT for patient 5 years of age and older.
California Children’s Services (CCS) – For members 0 -21 years of age – for CCS eligible conditions only.

 

AUTHORIZATION EXTENSION & MODIFICATION-

 

o    Extension – Authorizations expired 3 months from date of request. Call to be forward to UM for extension.

 o    Modification – Add or changing diagnosis code or cpt codes. To have provider fax the request to UM Dept or send message via portal to the UM Coordinator.