3.0 Authorizations / Approvals / Referrals / Benefits top
Note: The most current authorization policies may
be found on the
The two types of Authorization Forms used by the
ü Referral Authorization Forms (RAFs)
The Primary
Care Provider (PCP) when referring an
ü Treatment Authorization Forms (TARs)
· The provider completes a Treatment Authorization Request (TAR) before the service is performed.
· All Services that require a TAR will require a RAF, except for Administrative Members, and Medicare/Medi-Cal members when Medicare is the primary insurance. Administrative members are those not linked to a Primary Care Provider. Such members may self refer for covered benefits.
· The TAR may be submitted to Central Coast Alliance for Health by hand-delivery, FAX or mail.
· If possible all TARs should be submitted by FAX to avoid delays in the mail. Please include provider FAX number on TAR.
· Urgent TARs will be addressed within one business day, and all TARs will be acted upon within five (5) business days of receipt by the Plan. If the information submitted is insufficient to make an approval or denial, the TAR may be deferred for additional information.
· The provider submitting the TAR requesting service authorization will receive a faxed copy of the decision.
·
Each TAR has a unique number, and should only be used once,
for one member and one service authorization request. This unique number is used to facilitate
reimbursement.
Authorization of services is required as follows:
ü Linked Members
Eligibility must be verified prior to delivery of services. Refer to Section 2 - Membership and Eligibility, of this manual.
ü Administrative Members
Administrative
and Medi-Medi members when Medicare is primary payer for the requested services
may receive services without prior authorization from the
ATTN: Authorizations
Scotts
Or FAX to (831) 430-5850
3.1 General RAF / TAR
Requirements top
3.1.1 Referral Authorization Form (RAF)
Self-Referred
Services
There are two types of Alliance Medi-Cal Members, PCP linked and Administrative. Generally, a RAF is required from the member’s linked PCP as a referral to a specialist for evaluation and treatment. An Administrative Member may self-refer to a provider that will accept fee-for-services Medi-Cal rates. The exceptions are as follows:
· Limited Self-Referral Allied Health Services (Medi-Cal only) Title 22, Section 51304, addresses acupuncture chiropractic, prayer and spiritual healing, audiology, occupational therapy, podiatry, and speech therapy. These services are limited to a maximum of two self-referral services in any one calendar month. If the member exceeds the two-visit limit per month for occupational therapy, speech therapy or certain Podiatry procedure codes a RAF and TAR will be required. More than two monthly services of the other allied health care disciplines are not a covered benefit under the Medi-Cal program.
· Other self-referral Health Services; (OB/GYN, family planning, sensitive services), VSP (eye exams and glasses). This applies to Medi-Cal, Healthy Families, and Health Kids lines of business only.
· Healthy Families and Health Kids: Acupuncture and chiropractic services (up to the benefit maximum of 20 visits per calendar year for each).
· Healthy Kids and other lines of licensed business: Emergency services, family planning, sensitive services, and obstetrical and gynecological services.
3.1.2 General Information for TAR/RAF Submission
·
Medi-Medi
/ Other Health Care Coverage
- RAF is not required if the member has Part B Medicare coverage for professional services.
- RAF is required for elective hospitalization if the member does not have Part A Medicare.
- If Medicare or some other insurance is primary, there is no RAF required.
·
Basic
Rule
If a procedure or services requires a TAR, it will probably require a RAF (unless the member is an Administrative Member). Generally, the provider of the services (i.e., the provider expecting reimbursement) completes the TAR.
· Procedures requiring a TAR
If you have questions about which procedures require a TAR, please refer to the TAR/Non-Benefit List (only applicable to members over the age of 21) on the following web site http://www.medi-cal.ca.gov/default.asp, refer to your EDS Medi-Cal Provider Manual, or refer to the TAR/Non-Benefit list included here.
· Assistance
If you have reviewed the above resources and are unable to determine if a RAF or a TAR is required, please call our Service Authorization Coordinator at (831) 430-5506. Please have the CPT Procedure Code available to facilitate the research. You may also fax completed Authorization Inquiry Form, found in Section 7 of this manual, to (831) 430-5859.
·
Referral
Authorization Forms
A RAF is for the use of the member’s linked PCP when referring that member for specialty care. A specialist does not generate a RAF to refer a referred member to another specialist. Any subsequent referral must come from the member’s linked PCP.
3.1.3 Healthy Family and Healthy Kids Members
·
Long Term
Care
At the time of the initial
admission into a long term care facility (SNF or ICF), a RAF is required (if
the member is linked to a PCP). The
·
Newborns
Newborn examinations and Nursery Care are covered while the mother is hospitalized. Newborns may be eligible for care during the first 30 days unless the infant is eligible for Medi-Cal.
·
Ophthalmology
The evaluation and treatment of medical conditions does require a RAF. For visual acuity evaluations use Vision Services Plan (VSP) providers. A listing is in the Provider Directory. Vision correction services are a covered benefit for Medi-Cal, Healthy Families, and Healthy Kids members ONLY.
·
Optometry
Optometrists and Ophthalmologists
must be participating in the VSP program to provider refractory services to
3.1.4
·
Vision
and Dental Services
These services are not a covered benefit under this plan.
·
Acupuncture
and Chiropractic Care
These services do require a RAF and a TAR and are limited to 20 visits per calendar year.
3.2 Referral Authorization
Forms (RAFs) top
A Referral Authorization Form (RAF) is issued by the Primary Care Physician (PCP) to authorize services for their linked members who are case managed by the PCP. A RAF is not required for Administrative members, or members who have Medicare as their primary source of insurance.
Alliance Medi-Cal, Healthy Families, Healthy Kids, and
Alliance Care IHSS members also may need a RAF.
Please refer to the Authorization Matrix on the
RAFs are required for claims consideration on all elective
services. A RAF from a PCP to the
specialist can be as general or specific as the PCP desires. For instance, if a PCP wants to give broad
authorization and writes on the RAF, “services as needed” this means that the
Care should be taken by the PCP in completing RAFs since what is authorized will determine the scope and duration of services and claims paid for these services.
Referral Authorization Form (RAF)
Instructions
Member Information |
Fill in the member information as it appears on
the case management list or ID card. Also
provide the Member’s current |
Referral/Consultant Information |
Fill
in the complete name (first and last), address and telephone number of the
physician/provider you wish the member to see. This information is available in the |
Referral/Consultant Information - Continued |
|
Referral Information |
Check
appropriate Referral/Consultant Services (one only). |
Primary Care Physician’s Reason for Referral |
Please
indicate Diagnosis and ICD9 Code in the space provided. Please list the actual code number; the
written description is not sufficient.
Please indicate procedure, if applicable, and date(s) referral is
authorized. |
History / Comments |
Please
indicate this information. |
PCP Signature |
Only
the signature of the PCP or the Mid-Level will be accepted as authorization
for a referral. |
PCP Information |
Complete
all information required. If the
referral is made by a Mid-Level, please indicate the PCP’s name. |
A RAF form includes 3 copies which must be submitted as follows |
1.
White - send to the 2.
Canary - PCP keeps for their records. 3.
Pink - send to Referral Specialist. |
RAF Number |
Each
RAF has an unique number. The RAF must
be used only once, for one member and one provider. |
If a member is referred to an out of network provider, Primary Care Physicians
must indicate the reason why an
Please be sure to date and sign the RAF.
Mail the RAF to:
ATTN: Authorizations
Scotts
Or FAX to: (831) 430-5850
Sample RAF Form
3.3 Treatment Authorization Requests (TARs) top
A Treatment Authorization Request (TAR) is principally used to ensure that elective procedures, hospital admissions, services and supplies are medically necessary and covered as required by State Law.
Title 22, California Code of Regulations (CCR), Section 5100 3 (e) and (f) state “authorization may be granted only for Medi-Cal benefits that are medically necessary…and may be granted only for the lowest cost item or service covered by the program that meets the patient’s medical need.”
Use of Treatment Authorization Request (TAR) Form
The procedures for completing TARs can be found in the EDS Medi-Cal Provider manual, and in Section 3 in this manual. To expedite processing of TARs, providers should include:
Ø Medical justification;
Ø Documentation of recent history and physical to justify procedure; and
Ø Copies of relevant lab and radiology reports, and consultation reports as appropriate.
Submit TARs to:
Health Services Department
Or FAX to (831) 430-5850
Retroactive TARs
Retroactive TAR Submissions
1. TARs should be submitted prior to provision of a service unless it is medically urgent or will result in an unnecessary extension of a hospital stay.
2.
If a TAR is submitted after a service has been provided
or initiated to an
3.
If a TAR is submitted for a member who has obtained
retroactive eligibility, it must be received by the
The following are conditions whereby a TAR may be submitted for retroactive consideration:
Ø Member’s Medi-Cal eligibility was delayed.
Ø When “other coverage” will not pay the claim.
Ø Wheelchair repairs exceeding $500.00.
Ø When the patient hides Medi-Cal eligibility.
TAR Review
Only licensed medical professionals employed by the
TAR Status Table
Approved as Requested |
You may provide service as requested. Please
include the RAF# and TAR# on your claim. |
Approved as Modified |
Most Common Reasons for Approved as Modified TAR decisions
1. Fewer visits are authorized than were requested on the TAR. 2. The number of in-patient
days requested on the TAR is not within the length of stay guidelines for the requested procedure. 3. The dates of service requested on the TAR
do not match the dates that the member is |
Deferred |
Most Common Reasons for Deferred TAR
1. TAR incompletely filled out. TAR lacks: ·
Procedure (CPT) and/or diagnosis codes (ICD-9) ·
Narrative information as to procedure and/or codes that are being
requested. 2. Insufficient
medical information written on, or attached to the TAR to make the medical
decision. 3. Necessary
equipment pricing catalog pages not submitted |
Denied |
Common Reasons for a Denial 1. Patient is not an 2. Case is open to CCS for the particular medical diagnosis and/or the service 3. Services being requested are for dental services or mental
health, which are Medi-Cal services that are authorized by other agencies. 4. The documentation does not support the medical necessity for the
procedure/equipment. 5. The request was not submitted in accordance with the Alliance
Timeliness of Submission Policy. A denial letter will be
attached to the TAR giving an explanation for the denial. Appeal rights will also be included with
the TAR. If you need clarification on
why your TAR was denied, please call the Benefits vary across lines of business. Some authorization requests for Healthy Families members and enrollees in other lines of licensed business may be denied as plan exclusions. |
Pre-Approved TARs
Below is the list of procedures for adult patients, grouped by specialties, for which TARs will be pre-approved.
Clarifications regarding the list:
1. General criteria for eligible procedures:
a. Commonly performed
b. Negligible denial experience for medical appropriateness
c. Straightforward, non-complex pre and post op course
d. Adults (age 21+ ‑ many procedures for children may be covered by CCS)
2. Available to Alliance-contracted specialists in the specific areas of practice (eligible procedures do not “cross-over” to other disciplines).
3.
TAR will still be required for payment, but may be
submitted after the decision and the performance of the service.
4. Length of stays specified (parentheses after procedure). If a longer stay anticipated, please submit the TAR prior to the procedure and include the number of in-patient days being requested. Unanticipated complications may occur, which will be reviewed concurrently and authorized based upon clinical reasonableness. Only an Alliance Medical Director m