Medical Necessity Reviews Change & Prior Authorization Requests Reminder
| Date: | December 19, 2016 |
| To: | Health Plan of San Joaquin (HPSJ) Providers |
| From: | Medical Management Departmentt |
| Subject: | Medical Necessity Reviews Change & Prior Authorization Requests Reminder |
| Business: | Medi-Cal, MCAP (Medi-Cal Access Program, previously known as AIM) |
Health Plan of San Joaquin (HPSJ) strives to maintain, update and educate on the guidelines set forth by Medi-Cal (MCAL), while continually seeking ways to streamline processes. We believe the following will be helpful for your practice.
Medical Necessity Reviews
Effective: February 1, 2017
We are seeing a steady increase in the number of disputes requesting Medical Necessity Review when an authorization was not obtained before services have been rendered. These have been for:
- Additional visits such as physical/occupational therapy
- Elective surgeries
- Non-emergency services
Effective February 1, 2017, Medical Necessity Reviews from providers who fail to obtain prior authorization will no longer be reviewed for consideration, unless the dispute is one where it was thought that the member had other primary health coverage at the time services were rendered.
Prior Authorization Requests – Reminder
HPSJ has lifted the authorization requirements for several services in order to mainstream care for our members and will continue to need additional services in 2017. We want to remind you to please use DRE by accessing the Code Search Tool to identify services that require an authorization. This will help avoid unnecessary authorization requests or a delay in services, as well as ensure that authorizations requested are indeed for services that require one.
- HPSJ does not accept prior authorization requests after services have been performed.
- ALL authorizations must be submitted before services have been rendered, with the exception of emergency services, family planning & sensitive services, which do not require a prior authorization.
If you have any further questions, please contact our Provider Services Department at 209-942-6340.