Obtaining Prior Authorization
As a Community Care Health Member, you can self-refer to the following in-network specialists without a referral from your PCP: Emergency and Urgent Care, Dermatologist, Behavioral Health and Substance Abuse (Halcyon), Allergist, Chiropractic and Obstetrics and Gynecology. To see a specialist within the Community Care Health network of participating physicians, you are responsible for obtaining a referral from your Primary Care Physician (PCP). In the event you need to see a specialist outside of Community Care Health’s provider network, your provider will need to obtain an authorization from Community Care Health.
Utilization reviews include prior authorization, retrospective post service reviews and inpatient concurrent reviews. Some medical services may require prior authorization before you can access care. This means a physician must complete a Prior Authorization Request form and submit it with relevant medical information to Community Care Health. Information submitted will be evaluated and a decision will be made based on established clinical criteria.
How Community Care Health Makes Decisions about Your Care
Community Care Health uses evidence-based guidelines for authorization, modification or denial of health care services. Plan-specific guidelines are developed and reviewed on an ongoing basis by Community Care Health’s chief medical officer, the utilization management committee, and appropriate physicians who assist in identifying community standards of care. A copy of the guidelines used in the authorization process is available upon request.
At Community Care Health, we make utilization management decisions based on appropriateness of care and service after confirming health coverage. The doctors and nurses who conduct utilization reviews are not rewarded for denials of care or service, and there are no incentives for utilization management decision-makers that encourage decisions resulting in underutilization of health care services.
Independent Medical Review
You may also be eligible for an independent medical review (IMR). If you’re eligible for an IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services.
The California Department of Managed Health Care has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s website has complaint forms, IMR application forms and further instructions.