Claims and Eligibility

Prior Authorizations

Authorization required procedure codes

All elective services at Tertiary Level of Care centers require prior authorization. Requests must include justification for tertiary level of care. Tertiary Level of Care is specialized care that is requested by a member’s primary care provider (PCP) or specialist physician.

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Authorization Request Form (ARF) Download PDF Icon Submit along with clinical documentation to request a review to authorize member’s treatment plan.

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Authorization Request Form (ARF) for OneCare Connect  Download PDF Icon Submit along with clinical documentation to request a review to authorize OneCare Connect member’s treatment plan.

Inpatient

  • Scheduled inpatient admissions require prior authorization.
  • All emergency admissions require notification within 24 hours.
  • All post stabilization services require authorization by the Utilization Management department.

Outpatient

Unlisted, miscellaneous codes:

  • All unlisted, miscellaneous, “By Report” codes require prior authorization.
  • Each unlisted code requires:
    • Item description
    • Catalog page
    • Invoice

Wheelchair repairs:

  • CalOptima does not require prior authorization for wheelchair repairs less than $250.
  • Covered benefit and frequency limitations will apply.

Current authorization required complete procedure codes list

This is only a list of prior authorization procedure codes. It is not a complete description of benefits. For more information contact CalOptima or read the Member Handbook.

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Effective January 1, 2020 Download PDF Icon View the current prior authorization procedure codes.

Past authorization required complete procedure codes list

Effective October 1, 2019–December 31, 2019 

Effective July 1, 2019–September 30, 2019 

Effective April 1, 2019–June 30, 2019 

Effective January 1, 2019–March 31, 2019 

Effective October 1, 2018–December 31, 2018 

Effective July 1, 2018–September 9, 2018 

Important Information for Providers

  • COD Administrative members without an assigned primary care provider do not require authorization for initial consult visits.
  • Prior authorization is not required for UCI Medical Center specialty follow-up visits for CalOptima Community Network (CCN) members, except extended visits (99215).
  • Non-contracted providers: All services provided by non-contracted providers require prior authorization, regardless of whether the codes are listed on the CalOptima Prior Authorization Required List.
  • Codes not on the CalOptima Prior Authorization List are subject to Medi-Cal benefit and quantity limitations. Please check the Medi-Cal website for these determinations.
  • Behavioral health codes for Medi-Cal members (only) are included on this list.
  • No prior authorization is required for:

Emergency services
Urgent care visits
Sensitive services (which include family planning)
Sexually transmitted disease services
Abortion
Minor consent services

Human immunodeficiency virus (HIV) testing
Basic prenatal care services
Routine obstetrics services
Pediatric preventive services
Primary and preventive care services

CalOptima Community Network Prior Authorization

Primary Care (PCP)

No prior authorization is required for:

  • Assigned PCP; or
  • Affiliated group physician

Specialty Care (SCP)

All initial requests for specialty consults require a prior authorization from:

  • Assigned PCP; or
  • Contracted SCP

The initial prior authorization will include:

  • One specialty consult; plus
  • As many routine follow-ups as necessary (excluding office code 99215, which requires a new prior authorization)

Urgent Referrals (PCP and SCP)

Urgent referrals are only to be submitted if the normal time frame for authorization will:

  • Be detrimental to the patient's life or health; or
  • Jeopardize patient's ability to regain maximum function; or
  • Result in loss of life, limb or other major bodily function

All referrals not meeting urgent criteria will be downgraded to a routine referral request and follow routine turn-around times.

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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