Where I How to Submit Authorizations:
All referrals must be submitted 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 or;
Via Electronic submission, to:
Provider > Provider Web Portal >> Provider Portal
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 if requested service meets the direct access guidelines.
Standard/Routine Request:
- Medi-Cal = 5 business days
- CaIMedi-Connect = 5 business days
- Covered CA (CCA)= 5 business days
- Medicare = 14 calendar days
Urgent/Expedited Request :
- All lines of business (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 a copy of the criteria used to make the determination.
Contact the Utilization Management Department at: Toll Free > (866) 823-1415 or Local > (562) 888-1415.
Approval:
- Approval letter faxed to PCP & Specialist within 24 hours from approval date
- Approval letter mailed to member within 24 hours from approval date.
Delay/Pended:
- Health plan tracking number – Certain services require a tracking number from the health plan, cases are pended until we get tracking number.
- Pending Letter of Agreement (LOA) – IPA waiting for LOA to be signed by the specialist/facility.
- Pending for additional information – When the IPA’s Medical Director require additional information to make decision. While requesting these records a pended/delay letter is issued to the member and mailed within 24 hours; letter also faxed to PCP or specialist. Information must be provided to the IPA within the following time frame in order to make final decision.
- Medi-Cal – 4 days
- Molina -14 days (any line of business)
- Commercial – 45 days from deferral date
- Medicare (senior) – DO NOT DEFER – 14 days
Denial/Modification:
- 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 Division of Financial Responsibility)
Optometry: Vision care for some health plans are carved out except-
- Blue Shield Promise Medi-Cal – Eye exam only for adult over age 21 y/ eye exam and glasses for member under age 21 processed by the IPA.
- Regional Center: Developmental delay conditions for evaluation and possible therapy for member ages 0 -3 years of age. Provider to coordinate with Regional Center.
Early Start Program – Speech, Physical Therapy (PT)and Occupational Therapy (OT) for pediatric patient 3-5 years old. School District – Speech, PT, OT for patients 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. Requests/calls must be forwarded to UM Department for extension requests.
- Modification – Adding or changing diagnosis codes or CPT codes. Provider may fax the request to UM Department or send message via the portal to the UM Department.