As of January 1, 2019, consultations with an EPO Network or a Plus Network specialists do not require a referral/authorization.
Follow-up visits with most network contracted specialists, many procedures, and inpatient admission will still require prior authorization. Services provided without authorization will not be covered by the Plan. There are no retro authorizations.
The following specialties/services do not require an authorization:
- Emergency Room Services
- Urgent Care Services
- Chiropractic Care
- Outpatient Mental Health/Substance Abuse (not including Intensive Outpatient Program - IOP)
- OB/GYN (not including Perinatology)
You can request a more detailed listing of procedures that do not require prior authorization by contacting Health Plan Services.
Submitting a Request for Authorization
You can submit an authorization request and check the status of your request electronically through the Provider Portal. You can also fax an Authorization Form (PDF) to (661) 868-3291. The request must include:
- Supporting clinical documentation
Lack of complete documentation can result in a delay of the review process and denial of your request.
Your request will be reviewed for medical necessity and appropriateness. Benefit limitation or exclusion may apply. Care requested out-of-network will be redirected in-network for coverage by the Plan.
There is no out-of-network benefit on this Plan.
Complete requests will be processed within 5 business days. Requests submitted as Urgent or Emergent for medically necessary reasons will be expedited. Not obtaining prior authorization does not constitute an expedited review. You will be notified by fax when the determination of your request is final.
For inquiries regarding authorizations call (661) 868-3280 options 2 then 3.