Authorization Policies and Procedures
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Section 400: Health Services
Section 401: Quality Improvement
Section 402: Health Education and Disease Management
Section 403: Pharmacy
Section 404: Utilization Review
Section 405: Case Management
Section 406: Cultural and Linguistic
Section 401: Quality Improvement
HS 401-1401 Quality Issue Review
HS 401-1402 Quality Issue Corrective Action
HS 401-1501 Standards of Care
HS 401-1502 Adult Preventive Care
HS 401-1504 Network Clinical Standards for Breastfeeding
HS 401-1505 Childhood Preventive Care
HS 401-1506 Medical Necessity
HS 401-1507 Continuity of Care
Section 402: Health Education and Disease Management
Administrative:
HS 402-1101 Health Education and Promotion Program
Topic-Specific Education:
HS 402-1202 Diabetes Education Program
HS 402-1206 Hypertension Management
HS 402-1208 Therapeutic Abortion Counseling
HS 402-1210 Substance Abuse Intervention
HS 402-1213 Breast Self-Examination
HS 402-1214 Breastfeeding Promotion, Education and Counseling
HS 402-1215 Perinatal Transportation Assistance for Medi-Cal Members
Chronic Disease Management:
HS 402-1302 Physical Therapy for Chronic Back Pain and Other Longstanding Static Conditions
HS 402-1303 Diabetic Management
Section 403: Pharmacy
HS 403-1101 Pharmacy Operations Management
HS 403-1103 Pharmacy Authorization Processing
HS 403-1104 Pharmacy and Therapeutic Committee
HS 403-1105 Enbrel (Etanercept)
HS 403-1108 Leflunomide (Arava)
HS 403-1109 Non-FDA Approved Drugs and Herbal Remedies
HS 403-1110 Leukotriene Modifiers
HS 403-1111 SSRI Therapy Program
HS 403-1112 Therapeutice Equivalence of Generic Drugs
HS 403-114 Continuing Pharmacy Care for New Members
HS 403-1115 Non-Sedating Anti-Histamines
HS 403-1116 Anti-Obesity Drugs
HS 403-1117 New Anti-Hypertensive Drugs
HS 403-1118 Transdermal Patches
HS 403-1119 Non-formulary Migraine Drugs
HS 403-1120 Synagis (Palivizumab)
HS 403-1122 Hepatitis C Treatment Guidelines
HS 403-1123 Erectile Dysfunction Drugs
HS 403-1125 Somatropin (Serostim) Guidelines
HS 403-1126 Pharmaceutical Services Access
HS 403-1128 Other Non-Formulary Drugs
HS 403-1129 Long Acting Narcotics
HS 403-1130 Technology Assessment
HS 403-1131 Human Grown Hormone
Section 404: Utilization Review
General Utilization Management
HS 404-1101 Utilization Management Program
HS 404-1103 Appeals of UM Decision
HS 404-1109 Discloser of UM Process to the Provider
HS 404-1403 Missed Appointment and Patient Recall
HS 404-1405 Sterilization Consent Protocol
HS 404-1406 Member Access to Obstetrical and Gynecological Services
HS 404-1407 Initial Comprehensive Health Assessment
HS 404-1408 Hospital Transportation from PCP Office
HS 404-1409 Administrative Day Criteria
HS 404-1412 Non-Emergency Medical Transportation
Authorization Requests
HS 404-1201 Authorization Request Process
HS 404-1202 Authorization Request Timeliness
HS 404 1204 Hospital Stays Less than 24 Hours
HS 404-1205 Long Term Care Authorization Processing
HS 404-1207 TAR Response Times
HS 404-1210 TAR Procedure for Transplants
HS 404-1212 TAR Review Process for MRI
HS 404-1219 Skilled Nursing Authorizations
HS 404-1224 Vision Care Lenses
HS 404-1301 Authorization Time Period
Referral Authorization
HS 404-1303 Referral Consultation Request Process
HS 404-1306 Extended Referral Authorizations
HS 404-1307 Second Medical Opinion
HS 404-1309 Self-Referred Services
HS 404-1310 Out of Service Area Referrals
Provider-Related Issues
HS 404-1501 In Office Telephone Triage
HS 404-1503 Nurse Midwife Guidelines
HS 404-1504 Physician's Assistants
HS 404-1505 Nurse Practitioner Guidelines
HS 404-1506 Medical Assistants
HS 404-1507 Restrictions on Infant Formula Marketing
HS 404-1508 Infection Control Practices
HS 404-1509 Provider Deleting a Member from Case Management
HS 404-1510 Claims Appeal Override
Durable Medical Equipment (DME) and Medical Supplies
HS 404-1602 DME Authorization Process
HS 404-1603 Medical Supplies Authorization
HS 404-1604 Emergency Wheelchair Repairs
HS 404-1606 Provision of Breastfeeding-Related DME
HS 404-1607 Provision of Human Milk Bank Services
HS 404-1608 Restrictions on DME
HS 404-1610 DME and Medical Supplies under $100
HS 404-1209 TAR Review Process for TENs Unit
HS 404-1211 TAR Review Process for BiPAP and CPAP
HS 404-1214 TAR Review Process for Seat Lift
HS 404-1215 TAR Review Process for the Vest
HS 404-1216 TAR Review Process for Bone Stimulator and Ultrasound Device
Provision of Services
HS 404-1701 Provision of Medically Necessary Lactation Specialist Services
HS 404-1702 Provision of Family Planning Services to Members
HS 404-1703 Post Partum Hospital Stays
HS 404-1705 Dental Work for Alliance Members
HS 404-1706 Physical Therapy Guidelines
HS 404-1709 Pediatric Rehabilitative Therapies (Knox-Keene)
HS 404-1710 Pediatric Rehabilitative Therapies (Medi-Cal)
HS 404-1711 Authorization of MRI Studies
HS 404-1712 Biofeedback for Incontinence
Section 405: Case Management
HS 405-1101 Case Management Program
HS 405-1104 Coordination of Benefits for Veterans
HS 405-1106 Children with Special Health Care Needs
HS 405-1107 HIV-AIDS Home and Community Based Waiver Programs
HS 405-1301 Coordination of Care with Early Start
HS 405-1302 Early Intervention Services
HS 405-1303 Identification of Members with Developmental Disabilities
Section 406: Cultural and Linguistic
HS 406-1101 Cultural and Linguistic Services