• 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.

Speech Therapy, Occupational Therapy and Physical Therapy Authorization Request Tips for Providers

Wheelchair and hearing aid repairs:

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

• CalOptima Health Direct (CHOD) members without an assigned PCP do not require authorization for initial consult visits.
• Prior authorization is not required for UCI Medical Center specialty follow-up visits for CalOptima Health Community Network (CHCN) members, except for extended visits (99215).
• All services provided by non-contracted providers require prior authorization, regardless of whether the codes are listed on the CalOptima Health Prior Authorization Required List.
• Codes not on the CalOptima Health 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 and OneCare members are included on this list.
• All “By Report” codes require prior authorization.
• Prior authorization is NOT required for:
  • Emergency services
  • Urgent care visits
  • Sensitive services (including 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