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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyCenCal Health Prior Auth Policy Update | OpenPayer
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    CurrentCenCal HealthPolicy HS-MM49

    Utilization Review - Prior Authorization, Concurrent Review, and Retrospective Review

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    This policy governs CenCal Health's prior authorization, concurrent review, and retrospective review processes for determining the medical necessity, coverage, and appropriate amount, duration, and scope of health care services.

    Policy Summary
    PayerCenCal Health
    PolicyUtilization Review - Prior Authorization, Concurrent Review, and Retrospective Review
    Policy CodePolicy HS-MM49
    Change TypeAdministrative template revisionno material clinical or coverage change
    Effective DateJanuary 1, 2024
    Next Review DateN/A
    Key ActionObtain prior authorization before scheduled or elective admissions, services, or courses of treatment when authorization is required.
    SourceLink
    POLICY UPDATE CHANGES

    The revision history identifies a revision associated with implementation of a new policy template.

    3Utilization review types covered
    30 daysProvider training timeframe
    10 yearsAuthorization record retention
    8 categories

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Prior authorization exemptions
    Case-by-casePediatric medical necessity standard

    Utilization Review Coverage Criteria

    General Medical Necessity and Qualified Decision-Making

    CenCal Health bases Utilization Management (UM) authorization decisions on Medical Necessity, approved written criteria and/or guidelines, sound clinical practices, and evidence-based medical principles. UM activities include prospective, concurrent, and retrospective review and must be conducted consistently with the Plan's UM program description and applicable law.

    GENERAL MEDICAL NECESSITY AND QUALIFIED DECISION-MAKING

    • UM decisions approving, modifying, delaying, or denying a requested health care service must be based, in whole or in part, on Medical Necessity and must be consistent with approved, written UM criteria and/or guidelines supported by sound clinical practices and evidence-based medical principles.
    • Approved criteria and/or guidelines must be applied consistently and appropriately, based on all available relevant information, including the individual Member's needs and the characteristics of the local health care delivery system. The UM program must be developed, implemented, updated as needed and at least annually, and improved to ensure appropriate review and approval processes for Medically Necessary Covered Services.
    • CenCal Health and entities performing or delegated UM or Utilization Review functions must conduct those activities in accordance with applicable law, including Cal. H&S Code §1367.01 and the Plan's UM program description.
    • The Chief Medical Officer or medical director designee is responsible for the Utilization Review process and must ensure that Medical Necessity determinations are made by qualified medical personnel, are not influenced by fiscal or administrative management, and are not subject to compensation structures that incentivize denying, limiting, or discontinuing Medically Necessary services.
    • Personnel or contracted reviewers may approve a Provider request when the established UR process and approved written criteria and/or guidelines are followed and met.
    • A decision to deny a request or authorize an amount, duration, or scope less than requested must be made by a qualified health care professional with appropriate clinical expertise in treating the relevant medical or behavioral health condition, disease, or Long-Term Services and Supports need.

      Relevant specialty training, experience, or certification may demonstrate appropriate clinical expertise.

    • A qualified health care professional need not be an expert in every condition and may use other appropriate resources when making the determination.
    • Qualified health care professionals supervise review of decisions, including service reductions, and review all denials based in whole or in part on Medical Necessity.
    • CenCal Health ensures that authorization decisions and Appeals are made timely and are not unduly delayed when a Member's condition requires time-sensitive services.
    • CenCal Health discloses, or provides for disclosure of, the UR process and the criteria and/or guidelines used to authorize, modify, or deny health care services, as appropriate.

    Prior Authorization

    Prior authorization (PA) review is performed before scheduled or elective care that requires authorization.

    PRIOR AUTHORIZATION

    • CenCal Health applies approved clinical criteria and/or guidelines to determine Medical Necessity before a scheduled or elective admission, before rendering services, or before starting a course of treatment that requires PA.
    • CenCal Health consults with Providers as needed to determine Medical Necessity for a PA request, unless consultation would lead to undue delay in care.
    • PA requirements, procedures, and applicable timeframes are communicated to Network Providers, Members, and potential Members upon request. CenCal Health maintains telephone access for Providers seeking authorization and trains Network Providers on services requiring PA and the procedures and timeframes for obtaining authorization.
    • When requesting medical information from a Provider, CenCal Health requests only information reasonably necessary to determine whether to approve, modify, or deny the authorization request.

    Concurrent Review

    Concurrent Review evaluates care while treatment is being rendered.

    CONCURRENT REVIEW

    • CenCal Health applies approved clinical criteria and/or guidelines to determine Medical Necessity for outpatient observation status, admission to an acute care hospital or extended care facility, or approval of a continuing stay.

    Retrospective Review

    Retrospective Review evaluates services after they have been rendered.

    RETROSPECTIVE REVIEW

    • CenCal Health applies approved clinical criteria and/or guidelines to determine whether rendered services were Medically Necessary, were a Covered Benefit, or exceeded applicable coverage limitations.

    Pediatric Medical Necessity (Members Under 21)

    For Members younger than 21 years of age, Medical Necessity is determined under the EPSDT standard on a case-by-case basis.

    PEDIATRIC MEDICAL NECESSITY

    • The service is reasonable and necessary to protect life, prevent significant illness or significant disability, alleviate severe pain, or diagnose or treat disease, illness, or injury.
    • The service is necessary to achieve age-appropriate growth and development, attain, maintain, or regain functional capacity, or improve, support, or maintain the child's current health condition.
    • The service meets the EPSDT Medical Necessity standard under 42 U.S.C. §1396d(r)(5).

      CenCal Health must determine Medical Necessity case by case, taking into account the individual needs of the child.

    Mental Health and Substance Use Disorder Parity

    CenCal Health applies authorization requirements consistently across medical/surgical, mental health, and Substance Use Disorder (SUD) benefits.

    MENTAL HEALTH AND SUD PARITY

    • Policies, processes, strategies, evidentiary standards, and other factors used for UM or UR are applied consistently to medical/surgical, mental health, and SUD services and benefits.
    • Quantitative Treatment Limitations (QTLs) and Nonquantitative Treatment Limitations (NQTLs) are not imposed more stringently on covered mental health or SUD services than on medical/surgical services.

    CenCal Health does not apply PA requirements to Emergency Services, basic prenatal care, initial mental health and SUD assessments, family planning services, sexually transmitted disease services, HIV testing, Preventive Care services including immunizations, Minor Consent Services, Indian Health Service Programs, or medication management.

    CenCal Health implements a specialty referral system to track and monitor referrals requiring PA and ensures that Network Providers are aware of specialty referral processes and tracking procedures. When PA is delegated, Subcontractors and Downstream Subcontractors must maintain systems to track and monitor referrals and provide documentation to DHCS upon request.

    Records relating to PA requests, including Notices of Action, must be retained for a minimum of ten years from the final date of the phaseout period or from completion of any audit, whichever is later.

    CenCal Health is not responsible for reviewing PAs for physician-administered drugs, medical supplies, enteral nutritional products, or Covered outpatient drug claims billed on a pharmacy claim by an outpatient pharmacy.

    CenCal Health reviews PAs for physician-administered drugs, medical supplies, and enteral nutritional products when billed on a medical claim.

    Authorization and Utilization Review Actions

    Prior Authorization

    Obtain Approval Before Scheduled Care

    Obtain prior authorization before a scheduled or elective admission, before rendering services, or before starting a course of treatment when PA is required. CenCal Health applies approved clinical criteria and/or guidelines to determine medical necessity before care begins.

    • Prior authorization applies to scheduled/elective admissions, services, and treatment courses identified as requiring PA.
    • Follow CenCal Health’s pre-service operating procedures and applicable authorization timeframes.
    Note

    Services Exempt from Prior Authorization

    Do not apply prior authorization requirements to the services listed below. These exemptions do not eliminate other applicable coverage, referral, or documentation requirements.

    • Emergency services and basic prenatal care
    • Initial mental health and substance use disorder assessments
    • Family planning, sexually transmitted disease services, and HIV testing

    Utilization Review Program Overview

    CenCal Health uses utilization review to evaluate the medical necessity, appropriateness, and efficiency of health care services, procedures, and facilities. Review may occur before care through prior authorization, while treatment is being rendered through concurrent review, or after treatment through retrospective review. Determinations use approved written criteria or guidelines grounded in sound clinical practice and consider the individual member's needs.

    Key Utilization Review Terms

    Concurrent Review
    DefinitionThe process of determining Medical Necessity while treatment is being rendered.
    TimingDetermination occurs during treatment.
    SettingThe treatment is being rendered in an inpatient setting.
    Retrospective Review
    DefinitionThe process of determining Medical Necessity after treatment has been given.
    TimingDetermination occurs after treatment.
    Review focusMedical Necessity is determined for treatment that has already been provided.
    Policy Summary
    PayerCenCal Health
    PolicyUtilization Review - Prior Authorization, Concurrent Review, and Retrospective Review
    Policy CodePolicy HS-MM49
    Change TypeAdministrative template revisionno material clinical or coverage change
    Effective DateJanuary 1, 2024
    Next Review DateN/A
    Key ActionObtain prior authorization before scheduled or elective admissions, services, or courses of treatment when authorization is required.
    SourceLink
    On This Page
    Utilization Review Coverage CriteriaAuthorization and Utilization Review ActionsUtilization Review Program OverviewKey Utilization Review Terms
    PA review is conducted consistently with approved clinical criteria and/or guidelines under policy MM-UM22, and required authorization notifications are issued under the Plan's Notification of Utilization Management Determinations policy and Cal. H&S Code §1367.01(h).
  1. CenCal Health maintains systems to track specialty referrals requiring PA, including authorized, modified, deferred, or denied referrals, referral timeliness, and requested out-of-network services. Delegated Subcontractors and Downstream Subcontractors must maintain comparable tracking systems and provide documentation upon request.
  2. Records relating to PA requests, including Notices of Action, are retained for at least ten years from the final date of the phaseout period or completion of an audit, whichever is later.
  3. Preventive care, including immunizations; Minor Consent Services; Indian Health Service Programs; and medication management
    4. Prior Authorization

    Medical-Claim Authorization Categories

    CenCal Health is not responsible for reviewing prior authorizations for physician-administered drugs, medical supplies, enteral nutritional products, or covered outpatient drugs billed on a pharmacy claim by an outpatient pharmacy. CenCal Health does review the listed categories when billed on a medical claim.

    • Physician-administered drugs billed on a medical claim
    • Medical supplies billed on a medical claim
    • Enteral nutritional products billed on a medical claim
    • Covered outpatient drug claims billed on a pharmacy claim by an outpatient pharmacy are excluded from CenCal Health PA review
    Prior Authorization

    Use the Specialty Referral System

    Use the specialty referral system for referrals requiring prior authorization. The system supports referral workflows and tracking for authorized, modified, deferred, or denied referrals, including requested out-of-network services.

    • Follow CenCal Health’s specialty referral processes.
    • When PA is delegated, use the applicable Subcontractor or Downstream Subcontractor referral system.

    Unsupported block type: documentation k

    Note

    Consult with the Plan When Needed

    Consult with CenCal Health when needed to support a medical-necessity determination for a prior authorization request. Consultation should not lead to undue delay in care.

    • Be available to discuss the clinical basis for the requested medical services.
    • Use CenCal Health’s provider telephone access for authorization support when appropriate.
    Documentation Required

    Track Referrals Requiring Authorization

    Track referrals requiring prior authorization through the specialty referral process and applicable tracking procedures. CenCal Health and delegated entities must monitor referral status and timeliness.

    • Track authorized, modified, deferred, and denied referrals.
    • Include information on requested out-of-network services where applicable.
    • Maintain referral documentation for the required retention period when applicable.

    Unsupported block type: denial_risk

    Unsupported block type: denial_risk

    Denial Risk

    Modified, Deferred, or Denied Authorization Request

    A provider may receive a decision to approve, modify, defer, or deny a service authorization request. For a modified, deferred, or denied referral or PA request, CenCal Health provides the member and/or authorized representative a Notice of Action in accordance with applicable requirements.

    • Provider notification covers approval, modification, delay, denial, or authorization for less than the requested amount, duration, or scope.
    • Member Notice of Action requirements apply to modifications, deferrals, and denials of requests for health care services.
    • Notifications follow HS-UM07 and applicable federal and state requirements.
    Prior Authorization
    DefinitionA formal process requiring a Provider to obtain advance approval.
    ScopeApproval covers the amount, duration, and scope of non-emergent Covered Services.
    Required actionThe Provider must obtain approval before the non-emergent Covered Services are provided.
    Medically Necessary or Medical Necessity
    Core standardReasonable and necessary services to protect life, prevent significant illness or significant disability, or alleviate severe pain.
    Treatment purposeServices must address disease, illness, or injury through diagnosis or treatment.
    Functional needsServices must include those necessary to achieve age-appropriate growth and development and attain, maintain, or regain functional capacity.
    Members under 21For Members less than 21 years of age, the service must meet the EPSDT standard of Medical Necessity.
    Child-specific reviewFor Members less than 21 years of age, Medical Necessity is determined on a case-by-case basis, taking into account the individual needs of the child.
    Adverse Benefit Determination
    Requested serviceDenial or limited authorization of a requested service, including determinations based on the type or level of a Covered Service, Medical Necessity, appropriateness, setting, or effectiveness.
    Authorized serviceReduction, suspension, or termination of a previously authorized Covered Service.
    PaymentDenial, in whole or in part, of payment for a Covered Service.
    TimelinessFailure to provide Covered Services in a timely manner or failure to act within the required timeframes for standard resolution of Grievances and Appeals.
    Other actionsDenial of a Member's request to obtain services out of Network when the Member is in an area with only one Medi-Cal managed care health plan, or denial of a Member's request to dispute financial liability.
    Notice of Action (NOA)
    DefinitionA notice of any action that impacts a Member's ability to obtain Covered Services or other benefits CenCal Health is required to provide under the Plan's contract with DHCS.
    IncludesA NOA includes, but is not limited to, a notice of an Adverse Benefit Determination for a requested health care service.
    Covered requestsThe notice may address requested Community Supports the Plan has elected to cover.