SERVICES REQUIRING PRIOR AUTHORIZATION
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1 S REQUIRING PRIOR AUTHORIZATION All Hospital Admissions (All Place of service 21 services require authorization.) ELECTIVE ADMISSIONS All hospital admissions require review by Gold Coast Health Plan Health Services Department. For elective admissions, prior authorization is required for the procedure and the hospitalization. Ambulatory Surgery LTC EMERGENCY ADMISSIONS While the admission for emergencies does not require prior approval, hospitals MUST notify Gold Coast Health Plan Health Services department within 24 hours or the next business day of the patient admission. All days will be reviewed for medical necessity. All Outpatient surgeries require pre-authorization. All Long Term Care and Skilled Nursing Services require authorization. Genetic Testing S0265 S3713 S3800 S3818-S3855 S3860-S3862 S3865-S3866 Home Health Care S9127-S S9490-S9810 S5180-S5181 S9208-S9214 S9122-S9124 S9125-S9131 T1021-T1022 Z6900, Z6902, Z6904, Z6906, Z6908, Z6910, Z6920 Effective: 2/1/2016 Page 1 of 5
2 Outpatient Diagnostic Studies (MRI, CT Scan, PET Scans, Nuclear Medicine Imaging, Trans-cranial Doppler, Sleep Studies) Pain Management All Speech Therapy X4300-X4320 X4544 Z5918-Z5920 Z5962 V5362 X4544 Occupational Therapy (Authorization required after 10 visits. Includes 1 evaluation and 9 visits.) Podiatry Services Z7600-Z G0398-G X4100 X4120 All services with provider type PO require authorization with the exception of services for the following: Pregnant members Members under the age of 21 Members who reside in a Long Term Care Facility Effective: 2/1/2016 Page 2 of 5
3 Physical Therapy (Authorization required after 10 visits includes 1 evaluation and 9 visits.) Chiropractic Services Only covered for the following members: Members 20 years of age and under. Members in a skilled nursing facility (long term care). Members who are pregnant. Chiropractic Services are also covered for adults when performed at a Federally Qualified Health Center (FQHC) or a Rural Health Center (RHC) (No prior-authorization required for first 2 visits per calendar month. Authorization required for any additional visits per calendar month.) Out of Network Services All OON services require authorization X3900-X Exceptions include: Family planning services (including pregnancy testing) Sexually transmitted disease testing and treatment HIV testing Abortion services Emergency Room services (facility and professional) Non-Participating Facility services require authorization. Non-Participating Provider services require authorization. These services do not require authorization and can be provided to members by any willing Medi-Cal provider. Renal, Hemo, and Peritoneal Dialysis Phototherapy (All Phototherapy requires authorization.) DME Dental Anesthesia No prior-authorization required E0202 S9098 S0812 Hyperbaric Oxygen Chamber A4575 C1300 Authorization required for purchase > $500 and rental > $200 per month. All dental anesthesia and IV sedation requires authorization when performed by a medical anesthesiologist. Effective: 2/1/2016 Page 3 of 5
4 Supplies Home Infusion Therapy S5035-S5036 S5497-S5523 S9325-S9368 S9370-S9379 S9400-S9404 S9490-S9810 S9494-S9497 Non Emergent Transportation Enteral Nutrition No prior-authorization required. Transportation covered by Ventura Transit. B4102-B4104 B4149 B4150-B4155 B4157-B4162 Prosthetics and Orthotics Prior authorization required only for services/equipment costing > $200. Hearing Devices L8614 V5140 V5030 V5150 V5040 V5170 V5050 V5180 V5060 V5190 V5070 V5210 V5080 V5220 V5120 V5230 V5130 V5265-V5275 V5928 Therapies: (Sclerotherapy, Proton Beam, Neutron Beam, MEG, IMRT) S2202 G G6015 Effective: 2/1/2016 Page 4 of 5
5 Injectables J2325 J1568 J0775 J1569 C9257 J1572 J7312 J3490 J7311 J3590 J3262 J0585-J0588 J0490 J7321 J0129 J7323 J1459 J7324 J1556 J7325 J1557 J7326 J1559 J1561 J1562 J1566 Hospice In-Network but Out of Area Z7106 Authorization required for all out of Ventura County providers including those who have contracts with GCHP. Exceptions include contracted DME and medical supply vendors. *The following services do not require authorization and can be provided to members by any willing Medi-Cal provider. Family planning services (including pregnancy testing) Sexually transmitted disease testing and treatment HIV testing Abortion services *Preventive and pre-natal care do not require prior-authorization but must be delivered by in-network providers. Effective: 2/1/2016 Page 5 of 5
Integrity Accountability Collaboration Trust Respect
S REQUIRING PRIOR AUTHORIZATION Only valid codes will be reviewed. Please refer to CMS/MC guidelines to verify validity. All Hospital Admissions (All Place of service 21 services require authorization.)
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