No Prior Authorization Required Process – Helpful Reminders

Thank you for your engagement and cooperation to support our No Prior Authorization Required process and goal to increase member and provider satisfaction.

Here are a few helpful reminders:

• If the Provider Prior Authorization code lookup tool states no authorization is required for in-network services, do not send the request to L.A. Care Health Plan’s Utilization Management Department to ensure an authorization is in place for claims payment.
   
• If the treating clinician recommends a referral to an L.A. Care Direct Network specialist, submit the request via fax to L.A. Care as we are required to track referrals. Prior authorization is not required.
   
• If the request is for medical supplies/items that exceed quantity or frequency limits, a prior authorization is required.
   
• This process applies when L.A. Care (not the Participating Physician Group or PPG) is responsible for the authorization.

Certain services will ALWAYS require an authorization from L.A. Care such as:

• Clinical trials
• Community Based Adult Services
• Experimental services
• Inpatient level of care (excluding admissions for the birth of a child)
• Long Term Care
• Rehabilitation
• Non-contracted providers (except dialysis)
• Recuperative care
• Skilled Nursing Facility
• Transplant
• Unlisted procedures/codes
• Medical supplies or items exceeding maximum allowable benefit or frequency limits                                    
   

Prior authorization is not required for emergency services, urgent care visits, sensitive services (which includes family planning), sexually transmitted disease services, abortion, minor consent services, human immunodeficiency virus (HIV) testing, basic prenatal care services, routine obstetric services, primary and preventive adult/pediatric services. Authorization is contingent upon member’s eligibility on date of service.

For any questions regarding:

• the No Prior Authorization Required process - please reach out to your Account Manager.
• a submitted authorization - please email our Utilization Management team.