Claims and Eligibility

Post-Stabilization

Non-Contracted Hospital Admission Process – Post-Stabilization

I. Prior Authorization is Required for Inpatient Post-Stabilization Services

CalOptima requires a non-contracted hospital to obtain prior authorization for medical necessary inpatient post-stabilization services before inpatient admission to the non-contracted hospital. An authorization is not required for emergency services. For the OneCare Connect (OCC) program, observation status does not require an authorization; however, if the treating physician is planning to admit an OCC Member under observation to inpatient, a prior authorization is required before the inpatient admission.

II. Requesting Prior Authorization for Inpatient Post-Stabilization Services from CalOptima

For Medi-Cal or OCC Members, who are enrolled in CalOptima Community Network or CalOptima Direct-Administrative (collectively, CalOptima Direct), non-contracted hospitals must request prior authorization for medical necessary inpatient post-stabilization services from CalOptima before inpatient admission. CalOptima requires the treating physician to provide a diagnosis and sufficient information reasonably necessary to make a decision to authorize medically necessary inpatient post-stabilization services.

The following two steps are required to request prior authorization:

1. Call the Utilization Management (UM) Department to obtain a tracking number:

  • 714-246-8686 (Option 2 for Inpatient) – Monday through Friday from 8am to 5pm, Pacific Standard Time (PST);
  • 714-403-1732 – Monday through Friday from 5:01pm to 7:59am PST and all day Saturday, Sunday, and holidays.

2. Once you have obtained the tracking number, fax the clinical information necessary to support your request to a nurse case manager using the fax number that was provided to you along with the tracking number. Please include your contact information (name, phone number, and fax number).

Contact Us
  • Providers and other health care professionals with questions regarding Medi-Cal, OneCare Connect, OneCare or PACE can call the Provider Relations department at 714-246-8600 or email: providerservices@caloptima.org

Electronic Data Interchange (EDI)
Provider Disputes
  • Dispute Process
    Review the payment dispute process for Medi-Cal and OneCare contracted providers

Prior Authorizations

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