Where I How to Submit Authorizations:
All referrals must be submit by the member ‘s PCP.
PCP may submit request on the IPA/Medical Group referral form with supporting documentation to the UM Dept.
Via Fax: (562) 888-9096
Via Electronic submission, go to:
Referral Turn around time
- 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.
- Medi-Cal = 5 business days
- CaIMedi-Connect = 5 business days
- CovCA = 5 business days
- Medicare = 14 Calendar days
Urgent/Expedited Request :
- All LOB (Medi-Cal, Medicare, CCA) – 72 hours
NOTIFICATION OF APPROVAL/ DENIAL /MODIFICATION/DELAY
Denials and modifications of authorization due to coverage determination and medical necessity determinations are based on medical criteria. Provider and member may request for a copy of criteria used to make the determination. Contact the Utilization Management Department at: Toll Free > (866) 823-1415 or Local > (562) 888-1415.
- Approval letter faxed to PCP & Specialist within 24 hours from approval date
- Approval letter mail to member within 24 hours from approval date.
- 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/facility
- 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 letter faxed to PCP & Specialist within 24 hours from approval date
- 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)
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.
- 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
- Extension – Authorizations expired 3 months from date of request. Call to be forward to UM for extension.
- Modification – Add or changing diagnosis code or CPTcodes. To have provider fax the request to UM Dept or send message via portal to the UM Coordinator.