For some types of care, your PCP or specialist will need to ask L.A. Care for permission before you get the care. This is called asking for pre-approval or prior authorization. It means that L.A. Care must make sure the care is medically necessary (needed).
Medically necessary services are reasonable and necessary to protect your life, keep you from becoming seriously ill or disabled, or reduce severe pain from a diagnosed disease, illness or injury. For members under the age of 21, Medi-Cal services include care that is medically necessary to fix or help relieve a physical or mental illness or condition.
The following services always need pre-approval (prior authorization), even if you get them from a provider in the L.A. Care network:
- Hospitalization, if not an emergency
- Services out of the L.A. Care service area, if not an emergency or urgent
- Outpatient surgery
- Long-term care or skilled nursing services at a nursing facility
- Specialized treatments, imaging, testing, and procedures
- Medical transportation services when it is not an emergency
- Major organ transplant
Emergency ambulance services do not require pre-approval (prior authorization).
Under Health and Safety Code Section 1367.01(h)(1), L.A. Care has 5 business days from when L.A. Care gets the information reasonably needed to decide (approve or deny) pre-approval (prior authorization) requests.
For requests a provider made or when L.A. Care finds that following the standard time frame could seriously endanger your life or health or ability to attain, maintain, or regain maximum function, L.A. Care will make an expedited (fast) pre-approval (prior authorization) decision. L.A. Care will give you notice as quickly as your health condition requires and no later than 72 hours after getting the request for services.
Clinical or medical staff such as doctors, nurses, and pharmacists review pre-approval (prior authorization) requests.
L.A. Care does not influence the reviewers’ decision to deny or approve coverage or services in any way.
If L.A. Care does not approve the request, L.A. Care will send you a Notice of Action (NOA) letter.
The NOA will tell you how to file an appeal if you do not agree with the decision.
L.A. Care will contact you if L.A. Care needs more information or more time to review your request.
You never need pre-approval (prior authorization) for emergency care, even if it is out of the network or out of your service area. This includes labor and delivery if you are pregnant.
You do not need pre-approval (prior authorization) for certain sensitive care services. To learn more about sensitive care services, visit the Sensitive Care section of this online handbook.
For questions about pre-approval (prior authorization), call Member Services at 1-888-839-9909 (TTY 711).