Post-Stabilization

Contracted and Non-Contracted Hospital Admission Process – Post-Stabilization

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 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.

II. Requesting Prior Authorization for Inpatient Post-Stabilization Services from CalOptima Health

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.

The following two steps are required to request prior authorization:

1. Call the Utilization Management (UM) Department to obtain a tracking number:

714-246-8686 (Option 2 for Inpatient) – Monday through Friday from 8am to 5pm, Pacific Standard Time (PST);
714-403-1732 – Monday through Friday from 5:01pm to 7:59am PST and all day Saturday, Sunday, and holidays.

2. 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 that was provided to you along with the tracking number. Please include your contact information (name, phone number, and fax number).

Providers and other health care professionals with questions regarding Medi-Cal, OneCare Connect, OneCare or PACE can call the Provider Resource Line at 714-246-8600 or email: providerservices@caloptima.org

Electronic Data Interchange (EDI)

Eligibility/Benefit Inquiry and Response (270/271)
When to use eligibility and benefit inquiry and response
Claim Status Inquiry and Response (276/277)
When to use claim status inquiry and response

Provider Disputes

Dispute Process
Review the payment dispute process for Medi-Cal and OneCare contracted providers

Prior Authorizations

Authorization required procedure codes
The authorization required procedure codes list for medical and outpatient services should be used for services rendered.

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