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 OneCare (HMO D-SNP) members, observation status does not require a prior authorization. However, if the treating physician is planning to admit a OneCare member under observation to inpatient, a prior authorization is required before the inpatient admission.

For Medi-Cal or OneCare members enrolled in CalOptima Health, both contracted and noncontracted hospitals must request prior authorization before admission for medically necessary inpatient post-stabilization services. 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. CalOptima Health has a licensed physician available seven days a week, 24 hours a day, to review and authorize Medically Necessary post-stabilization care services and to assist with coordinating the transfer of stabilized members in an emergency department to an appropriate network provider, if necessary.