Referencias y Autorizaciones

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.
• 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 Case Management referral form to refer a member to either the Complex Care or Care Coordination services. You can submit the form online or fax it to the Alliance.

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:

• La Alianza Portal del Proveedor.
• 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:

• Allergy treatments.
• Dermatology therapy.
• Home Health Services.
• MRI and unlisted CT scans.
• Physical, Occupational and Speech Therapy.
• Some podiatric treatments
• Non-emergent outpatient surgery.
• All implants.
• All non-emergency hospitalizations and non-routine obstetric deliveries.
• Medical supplies and DME.
• All requests for referral to out-of-area, non-contracted providers and facilities.
• 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.
• Drug that is not in the Alliance Drug Formulary or exceeds the limit of days, age, quantity or cost allowed per formulary. Please refer to Pharmacy Services to know more about submitting prior authorization requests for drugs.

For more detail, see the Manual del Proveedor 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 Committee (UMC). For medical necessity determinations, the Alliance utilizes evidence-based medical necessity criteria in a decision hierarchy.

Decision Hierarchy

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 UMC.
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.

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)

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