Post-Stabilization

CalOptima Health requires both contracted and noncontracted hospitals to obtain prior authorization before admission for medically necessary inpatient post-stabilization services. Prior authorization is not required for emergency services. For the OneCare Connect (OCC) Cal MediConnect Program (Medicare-Medicaid Plan), 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.

For Medi-Cal or OCC members enrolled in CalOptima Health Community Network or CalOptima Health Direct-Administrative (collectively, CalOptima Health Direct), both contracted and noncontracted hospitals must request prior authorization before admission for medically necessary inpatient post-stabilization services from CalOptima Health. CalOptima Health 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.