California Children’s Services (CCS)

The Alliance is responsible for processing and intaking appeals and grievances for CCS Members.

For more details on how members can file a grievance, visit our grievance webpage.

General authorizations (Non NICU/NON HRIF)

The Alliance will review referral requests and Treatment Authorization Requests (TARs) to determine authorization for CCS-eligible members. Providers can submit an Authorization Request Form via the Alliance Provider Portal, fax, or mail. The Alliance reviews for medical necessity.

For more information, see the Referrals and Authorizations page.

HRIF Authorizations (High Risk Infant Follow up)

Providers should send these requests to the Alliance. The Alliance sends the information to the county CCS office to open a case in the state system.

NICU authorizations (Neonatal Intensive Care Unit)

Providers should send these requests to the Alliance. The Alliance sends the information to the county CCS office to open a case in the state system.

The Alliance will authorize NICU stays based on the CCS policy for Medical Eligibility for Care in a CCS-approved NICU.

Authorization will only be provided for the level of services for which a NICU has been approved by DHCS. If the NICU is not CCS-approved, or if the level of care that is required by the member is above the NICU level of approval, the hospital must follow CCS guidelines for Stabilization, Transfer and Transport of a CCS-Eligible NICU Patient.

CCS members are covered for the evaluation and treatment of behavioral health diagnoses when related to a CCS medically eligible condition. The Alliance partners with Carelon Behavioral Health to provide these services. Members can either be referred by their provider or call Carelon directly at 855-765-9700.

For more information on services provided by Carelon Behavioral Health, see the Behavioral Health page.

The Alliance provides Complex Case Management and Care Coordination services to Alliance members who need assistance.

• Members: Call Member Services to request Case Management.
• Providers: Call 800-700-3874, ext. 5512. Fax completed referral form to 831-430-5852, ATTN: Case Management.

For details, see the Complex Case Management page.

The Alliance processes claims for all Alliance members with CCS eligible conditions according to standard policies and procedures with the following additions:

• CCS diagnosis code should only be listed on claims when treating the CCS condition.
• TAR or prior authorization numbers are required on the claim for claims processing.

For details, see the Claims page.

The Alliance is responsible for the identification of potential CCS medical eligibility and initiating referrals.

Providers can submit referrals to the Alliance or the county CCS office. The Alliance sends the CCS referral to the county, who makes the medical eligibility determination.

County CCS offices determine a child’s eligibility for the program. Providers should send program referrals to their respective county’s CCS office:

• Merced County
• Monterey County
• Santa Cruz County

The child also needs to be seen by paneled providers.

Under the WCM, CCS members/guardians can submit for approval for reimbursement for meals and lodging related to CCS services. The Alliance is responsible for processing and reimbursing as appropriate.

Prior approval for all meals and lodging costs is required, when possible. Requests should be made at least 5-7 days in advance for initial services or routine visits. Submit the to Pediatric Complex Care Management for review and processing.

Pharmacy benefits and authorization requirements for CCS WCM members are the same as those for Medi-Cal members. See the member pharmacy page for details.

Physician/facility-administered drugs (PADs) billed as a medical claim (“buy-and-bill"): Prior authorizations are reviewed by the Alliance.

Prior authorization requests can be submitted via:

• The Alliance Provider Portal.
• The Prescription Drug Prior Authorization Request Form or Treatment Authorization Request (TAR) Form (submit to the Alliance Pharmacy Department).

Note: Drugs used for treatment of HIV/AIDS/Hepatitis B, alcohol and heroin detoxification and dependency, clotting factor disorder and antipsychotic drugs are carved out to Fee-For-Service Medi-Cal. Procedures for Fee-For-Service reimbursement for carved out drugs can be found on the Medi-Cal website in the Part 2 manual for Pharmacy.