Prior Authorization Multiple Changes
| To: | HPSJ Providers |
| From: | Health Plan of San Joaquin – Provider Services Department |
| Subject: | Prior Authorization Multiple Changes |
| Business: | Medi-Cal and AIM |
Good news for our providers.
These Medi-Cal services will no longer require Prior Authorization for our contracted providers when performed as out-patient or office-based procedures:
- Colonoscopy, Sigmoidoscopy and Endoscopy
- Physical Therapy (PT) and Occupational Therapy (OT) will now allow up to 10 visits instead of the 6 visits previously allowed without prior authorization
- Any visits after the 10th visit will require prior authorization with treatment plan
- Casting removal
- Nerve Conduction Studies
- Echocardiography procedures (Codes 93303-93352)
- Ante partum Code Z1036 (pertains to Medi-Cal only)
- Chemotherapy services
- Dialysis treatment
- Allergy Antigen
- Allergy Immunotherapy
These services will always require Prior Authorization for our contracted providers:
- Speech Therapy (ST) requires prior authorization on all visits
- Genetic Testing requires prior authorization on all tests
- Home Infusion
- Hearing devices (Maximum allowable for hearing aids is $1,510)
Admissions for Delivery – In-patient Admissions for Deliveries do not require a prior authorization (PA). To allow for labor time, please note the following:
- If the stay is longer than 4 days post-vaginal delivery, a PA is required for the extended stay
- If the stay is longer than 6 days post-C-section, a PA is required for the extended stay
- In these cases the hospital must notify HPSJ with all necessary documentation and the case will be reviewed for prior authorization
NOTE: When unsure about services that may or may not require Prior Authorization, please use your Code Finder option in our provider portal, DRE. This handy tool will allow you to confirm whether the code requires a prior authorization.
If you have any further questions or need assistance to access DRE, please contact our Provider Services Department at (209) 942-6340.