CalOptima Direct Prior Auth Required List

Authorization Required Procedure Codes

The Authorization Required Procedure Codes List for Medical and Outpatient services should be used for services rendered on or after January 1, 2005.

Beginning October 1, 2013, all elective services at Tertiary Level of Care centers require prior authorization. Approval will require that services can only be provided at a tertiary level of care. Requests must include justification for that level of care.

Inpatient:

  • Scheduled inpatient admissions require prior authorization.
  • All Emergency Admissions require notification within 24 hours.
  • All post stabilization services require authorization by the Concurrent Review Department.

Outpatient:

  • Unlisted/Miscellaneous Codes: All unlisted/miscellaneous/'By Report' codes require prior authorization. Each unlisted code requires item description, catalog page and invoice.
  • Wheelchair repairs: Requests after September 15, 2008, CalOptima will no longer require Prior Authorization for wheelchair repairs costing a total of less than $250. Covered benefit and frequency limitations will apply. Below codes would apply to new wheelchairs or repairs costing a total of more than $250.
  • COD Administrative members without an assigned primary care provider do not require authorization for initial consult visits.

Procedure Code Lists

Authorization Required Complete Procedure List Effective 10/01/2018

Authorization Required Complete Procedure List Effective 07/01/2018-09/30/2018

Authorization Required Complete Procedure List Effective 04/01/2018-06/30/2018

Authorization Required Complete Procedure List Effective 01/01/2018-03/31/2018

Authorization Required Complete Procedure List Effective 10/01/2017-12/31/2017

Authorization Required Complete Procedure List Effective 07/01/2017-09/30/2017

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