Referrals and Authorizations

ED providers may refer directly to the following specialists for the referenced treatments without prior authorization:

• Orthopedic surgeons: for documented or suspected facture, sprains and strains.
• General surgeons: for chronic cholecystitis and systemic cholelithiasis.
• Ophthalmologists: for emergency retinal detachment; corneal abrasions, burns and retained foreign bodies; acute ocular infections; and glaucoma emergencies.
• Pain management: for acute or acute on chronic lumbar and/or cervical radiculopathy.

The Alliance provides Complex Case Management services to members with certain chronic illnesses, catastrophic diagnoses and other complex medical issues. For full details, see the Complex Cases page.

Alliance Care Coordination services help members with less complex, non-clinical needs such as durable medical equipment and transportation. See the Care Coordination page for a full list.

Use the Care Management Referral Form to refer a member to either the Complex Care or Care Coordination services.

The provider of service is responsible for obtaining Alliance approval prior to provision of certain services.

To request authorization, complete an Authorization Request (AR) form and submit it via:

• The Alliance Provider Portal.
• Fax to 831-430-5850.
• Mail to: Central California Alliance for Health, PO Box 660015, Scotts Valley, CA 95067-0012.

Services that require prior authorization include, but are not limited to:

• Dermatology therapy.
• Home Health Services.
• MRI and unlisted CT scans.
• Physical, Occupational and Speech Therapy treatment.
• Some podiatric treatments
• Non-emergent outpatient surgery.
• IRF/ARU, SNF/LTC, RCFE, Sub-Acute, LTACH.
• Non-Emergency Medical Transportation.
• All implants.
• All non-emergency hospitalizations, except for an obstetrical delivery.
• Some medical supplies and Durable Medical Equipment (DME).
• Requests for referral to out-of-area, non-contracted providers and facilities.
• Some exceptions apply to Alliance TotalCare members. For more detail, see the Provider Manual.
• Referrals for services to be provided outside of the Alliance service area, for all members except Medi-Cal administrative members.
• Requests for referral for WCM CCS-eligible members.
• Requests for maintenance and transportation benefits for WCM CCS-eligible members.
• Medical nutrition therapy and enteral nutrition products require prior authorization.
• Drugs that are not in the Alliance Drug Formulary or exceed the limit of days, age, quantity or cost allowed per formulary. Please refer to Pharmacy Services to learn more about submitting prior authorization requests for drugs.

For more detail, see the Provider Manual and the Authorization Request Process Policy.

The Alliance’s Utilization Management (UM) program implements a comprehensive, integrated process that actively:

• Evaluates and manages the utilization of health care resources delivered to our members.
• Pursues identified opportunities for improvement.

The UM program ensures that:

• Members receive the appropriate quantity and quality of health care services.
• Service is delivered at the appropriate time.

The UM program verifies equitable access to appropriate, cost-effective health care resources for all members. For authorization purposes, a requested service or medical equipment is approved if it is a covered benefit and is determined to be medically necessary.

The UM program provides a reliable mechanism to review, monitor, evaluate and address utilization-related concerns as well as recommend and implement interventions to improve appropriate utilization and resource allocation.

To achieve appropriate and standardized decisions, the UM program processes requests using a systematic, consistent application of utilization management criteria. Clinical care decisions are determined by the Alliance's qualified, experienced UM team using evidence-based guidelines developed and approved by the Alliance's Utilization Management Work Group (UMWG). For medical necessity determinations, the Alliance utilizes evidence-based medical necessity criteria in a decision hierarchy.

Copies of Alliance Utilization Management policies can be viewed in the Alliance Policies section below.

Decision Hierarchy

Any of the following guidelines may be used, depending on the request. Even if a request is not listed as covered under one of these guidelines, requests will still be reviewed for medical necessity. The order of the hierarchy may vary depending on the Member’s Alliance Line of Business (TotalCare, Medi-Cal, or IHSS).

1. Medi-Cal Medical Necessity Guidelines (when available).
2. Evidence-based guidelines, such as:
   • MCG care guidelines.
   • Medicare (CMS) Guidelines.
3. Title 22 California Codes of Regulation Division 5 criteria.
4. Alliance Health Services and Pharmacy guidelines, policies and procedures approved by the UMWG.
5. Consensus statements and nationally recognized standards of practice.
6. Guidelines developed by other health plans.
7. Expert opinion:
   • Clinical advisors serving on Alliance committees.
   • Outside independent medical review.
8. For WCM CCS-eligible members:
   • Use all current and applicable CCS program guidelines, including CCS program regulations, CCS numbered letters, and CCS program information notices in developing criteria for use by the plan’s chief medical officer or the equivalent and other care management staff for the member’s CCS-eligible condition.
   • In cases in which applicable CCS clinical guidelines do not exist, use evidence-based guidelines or treatment protocols that are medically appropriate given the member’s CCS-eligible condition.
9. For IHSS only: Behavioral Health’s Utilization Review criteria, also known as medical necessity criteria, is any criteria, standards, protocols, or guidelines used by healthcare service plans to approve, modify or deny an authorization request. The Alliance does not apply criteria or guideline review for the treatment of mental health and substance use disorders for the IHSS LOB, as we do not review or require authorization for such services, either prospectively, concurrently, or retrospectively. The Alliance sponsors a formal education program provided by the nonprofit clinical specialty association World Professional Association for Transgender Health (WPATH) to educate plan staff who conduct utilization review or make Medical Necessity determinations for transgender services. The Alliance provides these criteria and materials to providers and Alliance members at no cost. If you would like to request free copies of these materials, call the Alliance’s Member Services at 800-700-3874 (TTY: 800-735-2929 or 711). The Alliance conducts interrater reliability testing and run reports to achieve an interrater reliability pass rate of at least 90 percent. Interrater reliability testing measures the consistency in decision making by individuals authorized to determine whether services are Medically Necessary. See UM Policy 404-1101 – Utilization Management Program for more information.

Other Supplemental Resources

• Advisory Committee for Immunization Practices (ACIP) Vaccine Recommendations
• American Academy of Pediatrics Clinical Practice Guidelines Summary
• American College of Radiology Appropriateness Criteria
• American Diabetes Association
• Center for Disease Control (CDC) and Prevention
• Johns Hopkins Medicine Research
• Mayo Clinic Clinical Resources
• National Comprehensive Cancer Network: About Clinical Practice Guidelines
• American Board of Medical Specialties (ABMS)
• National Heart Lung and Blood Institute: U.S. Clinical Practice Guidelines Summaries  
• U.S. Preventive Services Task Force
• Wheeless’ Textbook of Orthopedics
• UpToDate: Evidence-Based Clinical Decision Support
• National Institute for Health and Care Excellence (NICE)
• New England Journal of Medicine (NEJM)
• Diseases & Conditions: Medscape Reference
• NEJM Journal Watch
• About MEDLINE and PubMed: The Resources Guide
• Centers for Medicare & Medicaid Services (CMS)
• WPATH | World Professional Association for Transgender Health

A medical letter or a pharmacist letter may also be a supplemental resource.

• 404-1101 Attachment A Utilization Management Program Doc Review Approval
• 404-1101 Utilization Management Program
• 404-1102 Inpatient Review
• 404-1103 Hair Removal
• 404-1108 Monitoring of Over/Under Utilization of Services
• 404-1109 Disclosure of Utilization Management Process to Providers, Members, and the Public
• 404-1110 Utilization Management Committee Responsibilities and Functions
• 404-1111 Utilization Management Assessment Process
• 404-1112 Medical Necessity- The Definition and Application of Medical Necessity Provision to Authorization Requests
• 404-1113 External Independent Medical Review
• 404-1114 Attachment A Matrix Continuity of Care Reqs
• 404-1114 Continuity of Care
• 404-1115 Terminal Illness
• 404-1201 Authorization Request Process
• 404-1202 After-Hours Availability of Plan or Contract Physician
• 404-1203 Surgical Treament of Varicose Veins
• 404-1204 Laparoscopy Cholecystectomy Authorization Process
• 404-1303 Referral Consultation Request Process
• 404-1305 Screening and Referral of Medically Eligible Children to California Children’s Services (CCS) Program
• 404-1306 Extended (Standing) Referral Authorizations
• 404-1307 Medical Second Opinions
• 404-1308 Enhanced Care Management Overview
• 404-1309 Member Access to Self Referred Services
• 404-1310 Attachment A Requirements for Referral of Members to Specialty P
• 404-1310 Authorization Process for Referrals to Out of Area and Non-Contrac
• 404-1312 Standing Referrals to HIV/AIDS Specialists
• 404-1313 Primary Care Provider Responsibilities Including Case Management and the Promotion of Patient Centered Medical Home
• 404-1314 Children with Special Health Care Needs (CSHCN)
• 404-1316 Early Intervention Services
• 404-1401 Sterilization Consent Protocol
• 404-1520 Administrative Day Criteria
• 404-1521 Hospital Stays Where Discharge, Death or Transfer Occurs on the Day of Admission
• 404-1523 Post-partum Hospital Stays
• 404-1524 Long-Term Care for Medi-Cal Members
• 404-1525 Attachment A Skilled Nursing Facility Levels of Care Matrix
• 404-1525 Skilled Nursing Program Policy for Medi-Cal
• 404-1526 Provision of Hospital or Skilled Nursing Facility Sitters for Cognitively Impaired Alliance Members
• 404-1527 Palliative Care
• 404-1528 Adult Complex Case Management
• 404-1529 Post Discharge Meal Delivery Program Benefit
• 404-1530 Pediatric Complex Case Management
• 404-1601 Attachment A DME Authorization Matrix Providers
• 404-1601 Durable Medical Equipment (DME) Authorization
• 404-1603 Medical Supplies Authorizations
• 404-1605 Wheelchair Authorization Guidelines
• 404-1609 Negative Pressure Wound Therapy Pumps
• 404-1611 Transcutaneous Electrical Nerve Stimulation (TENS) Unit Authorization Review Process
• 404-1612 BiPAP and CPAP Units Authorization Process
• 404-1613 Seat Lift Chairs Authorization Request Review Process
• 404-1614 High Frequency Chest Wall Oscillation Devices (Vest) Authorization
• 404-1615 Nebulizers
• 404-1617 Foot Orthotic and Prosthetic Appliances Guidelines
• 404-1618 Compression Garments
• 404-1702 Provision of Family Planning Services to Members
• 404-1703 Alliance Members with Veterans Benefits
• 404-1704 Attachment A Medical Clearance for Dental Anesthesia
• 404-1704 Attachment_B_PA_TAR_Reimbursement Scenarios
• 404-1704 Dental Anesthesia for Alliance Medi-Cal Members
• 404-1705 Dental Services for Medi-Cal Members
• 404-1706 Physical Therapy Guidelines
• 404-1707 Acupuncture Services for Medi-Cal Members
• 404-1708 Chiropractic Services
• 404-1709 Therapies for Knox Keene Lines of Business
• 404-1710 Pediatric Therapies for Medi-Cal Recipients
• 404-1711 Sleep Study (Polysomnopraphy/Sleep Disorder Testing) Authorization
• 404-1712 Biofeedback Training for Urinary Incontinence
• 404-1713 Electromyography, Nerve Conduction Studies
• 404-1714 Technology Assessment
• 404-1715 Genetic Testing
• 404-1716 Epidermal Nerve Fiber Density Studies
• 404-1719 Home Health Care
• 404-1720 Phase II Cardiac Rehabilitation Services
• 404-1720 Private Duty Nursing EPSDT Benefit
• 404-1721 Antepartum Fetal Surveillance
• 404-1723 Major Organ Transplant Authorization Process
• 404-1724 Hospital Transportation from PCP Office
• 404-1725 Non-Medical Transportation
• 404-1726 Non-Emergency Medical Transportation
• 404-1727 Provision of Telehealth Services to Alliance Members
• 404-1728 Contraceptive Products and Services
• 404-1729 Pulmonary Rehabilitation Services
• 404-1730 Medical Nutrition Therapy
• 404-1731 Medication Assisted Treatment
• 404-1732 Maintenance and Transportation for Members with CCS Eligibility
• 404-1733 Total Joint Replacement
• 404-1734 Allergy Immunotherapy
• 404-1734 Attachment A: Immunotherapy Authorization Request Checklist
• 404-1735 Long-Term External Cardiac Event Monitoring
• 404-1736 Continuous Glucose Monitoring
• 404-1737 Panniculectomy & Other Lipectomy
• 404-1738 Community Health Worker Services
• 404-1739 Doula Services
• 404-1743 Intermediate Care Facility/Developmental Disabled Homes
• 404-1744 Systems Control Policy
• 404-1745 Community Supports Policy for Medically Tailored Meals
• 404-1746 Community Supports Policy for Housing Deposits
• 404-1747 Community Supports Policy for Housing Transition Navigation Services