Authorizations

A referral is the process of a Primary Care Provider (PCP) sending a member to another provider, like a specialist, for consultation or services that are not be provided by the PCP.

Some services do not require a Referral Authorization Form (RAF) and can be accessed by members directly, click on these links to learn more about RAFs, or view our Frequently Asked Questions document.

Certain medical procedures require prior authorization to ensure medical necessity and appropriateness of care. CenCal Health has made it easy to determine if a TAR is required by utilizing the HCPCS/CPT Procedure Code – Prior Authorization Requirement Search Tool for providers.

Learn more about TARs

Documentation of Medical Necessity for Intravenous Sedation & General Anesthesia for Dental Procedures Referral Slip

Second Opinion

CenCal Health members may request a second medical opinion regarding a recommended procedure or service through their PCP. The plan must review the request for medical necessity.

Certain Medi-Cal covered services do not require prior authorization, irrespective of whether the member seeking the service is enrolled in CenCal Health.

• Family planning, sexually transmitted diseases, abortion and HIV testing
• Acupuncture, chiropractic, audiology, physical therapy (Rx may be required)
• Emergency services
• First month of eligibility assigned to CenCal Health as Special Class and/or Members residing in a Long Term Care facility

To obtain more information about services not requiring prior authorization, please call Provider Services at (805) 562-1676.

Certain medical procedure require prior authorization to ensure medical necessity and appropriateness of care. CenCal Health has made it easy to determine if a TAR is required by utilizing the HCPCS/CPT Procedure Code-Prior Authorization Requirement Search Tool for providers.

Any request for a medication via CPT-Code (i.e J-Code) to be administered at a provider’s office or infusion/hospital facility must be submitted as a medical authorization request (treatment authorization request – TAR) through the Provider Portal.

Prior authorization for high-tech imaging services is required to be completed by the ordering provider.

CenCal Health covers transportation to and from medically necessary services, such as doctor appointments, specialty mental health, substance use disorder, dental, pharmacy pick up, medical supply pick up and more.

CenCal Health partners with Ventura Transit System (VTS) to schedule and manage transportation services for our member. Non-Emergency Medical Transportation (NEMT) and Non-Medical Transportation (NMT) are covered services for CenCal Health members.

Medical Transportation Services Reference Guide

Non-Medical Transportation (NMT)

• Members can receive transportation to medically necessary services, including but not limited to, specialty mental health, substance use disorder, dental, pharmacy pick up, medical supply pick up.
• Scheduled transportation of members to medical services by bus, passenger car, taxicabs, or other forms of public or private conveyances.

Non-Emergency Medical Transportation (NEMT)

• Members can receive transportation services when the member’s medical and physical condition is such that transport by ordinary means of public or private conveyance could cause harm to the patient and transportation is require for medical services.
• Scheduled transportation is covered when a Physician Certification Statement (PCS) Form is signed by a physician, or as appropriate, by a dentist, podiatrist, or mental health or substance use disorder provider and approved by CenCal Health.

Authorization Requirements:

• NMT services do NOT require a Physician Certification form.
• All NEMT services require a Physician Certification Statement (PCS) Form.
• The PCF form must be initiated by the member’s Referring Physician and faxed to CenCal Health’s Health Services Department at (805) 681-3071 prior to issuing authorization approval.

Transportation Eligibility:

• Members must be eligible at the time of service.
• Transportation must be requested 5-7 business days in advance of the trip to ensure time to process the authorization and coordinate transportation.
• The transportation provided must be the least costly method that meets the member’s needs.
• VTS and CenCal will coordinate along with the member’s physician to determine the type of transportation required. A screening will be completed by all parties upon request to ensure the level of transportation need for the member.

Types of NEMT Transportation

AMBULANCE service may be used for:

1. Transfers from an acute care facility to another acute care facility.
2. Transport for members who have recently been placed on oxygen (does not apply to members with chronic emphysema who carry their own oxygen for continuous use).
3. Transport for members with chronic conditions who require oxygen if monitoring is required.
4. Transfers between facilities for members who require continuous intravenous medication, medical monitoring or observation.

LITTER VAN service may be used when the member’s medical and physical condition does not meet the need for NEMT ambulance services, but meets both of the following:

1. Requires that the member be transported in a prone or supine position, because the member is incapable of sitting for the period of time needed to transport.
2. Requires specialized safety equipment over and above that normally available in passenger cars, taxicabs or other forms of public conveyance.

WHEELCHAIR VAN service may be used when the member’s medical and physical condition does not meet the need for litter van services, but meets any of the following:

1. Renders the member incapable of sitting in a private vehicle, taxi or other form of public transportation for the period of time needed to transport.
2. Requires that the member be transported in a wheelchair or assisted to and from a residence, vehicle and place of treatment because of a disabling physical or mental limitation.
3. Requires specialized safety equipment over and above that normally available in passenger cars, taxicabs or other forms of public conveyance.
4. Members with the following conditions may qualify for wheelchair van transport when their providers submit a signed Physician Certification Statement (PCS) form:

• Members who suffer from severe mental confusion.
• Members with paraplegia.
• Dialysis recipients.
• Members with chronic conditions who require oxygen but do not require monitoring.

AIR Transport for NEMT will be provided only when transportation by air is necessary because of the member’s medical condition or because practical considerations render ground transportation not feasible.  The necessity for transportation by air shall be substantiated in a written order of a physician, dentist, podiatrist, or mental health or substance use disorder provider.

Members and/or Providers may contact Ventura Transit System (VTS) directly at (855) 659-4600 for transportation services or please call CenCal Health’s Member Services Department at 1 (877) 814-1861 for assistance.