Post-Stabilization Services
Contracted and Noncontracted Admission Process
I. Prior Authorization Is Required for Inpatient Post-Stabilization Services
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 members, observation status does not require prior authorization. However, if the treating physician is planning to admit a OneCare member under observation to inpatient care, prior authorization is required before the inpatient admission.
II. Requesting Prior Authorization for Inpatient Post-Stabilization Services From CalOptima Health
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 24/7 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.
The following two steps are required to request prior authorization:
- Call the Utilization Management (UM) department to obtain a tracking number:
- 714-246-8686 (Option 2 for inpatient)
- Monday through Friday
- 8 a.m. to 5 p.m., PST
- 714-403-1732
- Monday through Friday from 5:01 p.m. to 7:59 a.m. PST
- All day Saturday, Sunday and holidays
- 714-246-8686 (Option 2 for inpatient)
- 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 provided with the tracking number. Please include your contact information (name, phone number and fax number).